Skip to main content Skip to main navigation menu Skip to site footer

Variation of conus medullaris location based on magnetic resonance imaging of the lumbar spine in Indonesia: A study at Dr Soetomo General Academic Hospital, Surabaya, Indonesia

  • Aria Adhiatma ,
  • Christrijogo Sumartono Waloejo ,
  • Belindo Wirabuana ,
  • Eddy Rahardjo ,


Introduction: Recognition of conus medullaris position, contains lumbosacral plexuses which supply motor and sensory innervation to the whole lower limb, pelvic and perineal areas, is critical to avoid injury due to lumbar procedures, such as spinal anesthesia and lumbar punctures. This study aimed to investigate the position of conus medullaris among Indonesians through magnetic resonance imaging (MRI) of the lumbar spine at Dr. Soetomo General Academic Hospital in order to minimize the risk of conus medullaris trauma.

Methods: A retrospective study was conducted to investigate the conus medullaris level and its correlation to gender and age Indonesian patients. The data were collected from lumbar MRI at Dr Soetomo General Academic Hospital during January 2020 and December 2021. The level variations of conus medullaris were recorded and determined as the highest, lowest and most common location descriptively.

Results: A total of 257 patients (126 male and 131 female) were included. The highest level of conus medullaris was in T11-T12 vertebrae (five patients). There were 12 patients in T12 vertebrae, T12–L1 in 86 patients, L1 in 62 patients, L1–L2 in 76 patients, and L2 in 12 patients. The lowest level was in between L2 and L3 vertebrae in 4 patients. Gender and age had no association with conus medullaris level.

Conclusion: The lowest level of conus medullaris was in between L2 and L3 vertebrae. The lumbar procedure such as punctures should be done below the L3 to avoid conus medullaris puncture trauma.


  1. Morgan GE, Mikhail MS. Morgan & Mikhail's clinical anesthesiology: McGraw-Hill Education; 2018.
  2. Moon M-S, Jeong J-H, Kim S-J, Kim M-S, Choi W-R. Magnetic Resonance Imaging Observations of the Conus Medullaris in a Korean Population. Asian Spine J [Internet]. 2018/12/21. 2019 Apr;13(2):313–7. Available from:
  3. Rahmah A, Utariani A, Basori A. Profile Hemodynamics (Blood Pressure And Heart Rate) Changes in The Use of Adrenaline in Cesarean Section With Spinal Anesthesia at Dr Soetomo Surabaya Hospital. Indones J Anesthesiol Reanim [Internet]. 2020;2(1):27. Available from:
  4. Capdevila X, Aveline C, Delaunay L, Bouaziz H, Zetlaoui P, Choquet O, et al. Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study. Adv Ther [Internet]. 2019/12/11. 2020 Jan;37(1):527–40. Available from:
  5. Budianto F, Setiawan P, Hamzah H, Yulianti E. Comparing Alteration of MMSE (Mini-Mental State Examination) Scores as Cognitive Function Test in Geriatrics After General and Regional Anesthesia. Indones J Anesthesiol Reanim [Internet]. 2020;2(2):47. Available from:
  6. Waloejo CS, Sulistiawan SS, Wirabuana B, Putri HS, Johansyah A, Hidayati HB. Relation of the successful block regional anesthesia with increased peripheral venous circumference and peripheral skin temperature at distal part of the block. Anaesth, Pain & Intensive Care. 2021;25(4):457-62.
  7. Liu A, Yang K, Wang D, Li C, Ren Z, Yan S, et al. Level of conus medullaris termination in adult population analyzed by kinetic magnetic resonance imaging. Surg Radiol Anat [Internet]. 2017;39(7):759–65. Available from:
  8. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth [Internet]. 2009;102(2):179–90. Available from:
  9. Widhiyanto L, Japamadisaw A, Hernugrahanto KD. A demographic profile of cervical injury: an Indonesian single tertiary hospital study with 6 months to 1-year follow-up. Egypt J Neurol Psychiatry Neurosurg [Internet]. 2021;57(1). Available from:
  10. Wicaksono SA, Priambodo B. Occurrence of Foot Drop After Spinal Anesthesia. JAI (Jurnal Anestesiol Indones [Internet]. 2019;11(1):42. Available from:
  11. Reynolds F. Damage to the conus medullaris following spinal anaesthesia. Anaesthesia [Internet]. 2001;56(3):238–47. Available from:
  12. Aldrete JA. Neurologic deficits and arachnoiditis following neuroaxial anesthesia. Acta Anaesthesiol Scand [Internet]. 2002;47(1):3–12. Available from:
  13. Kingwell SP, Curt A, Dvorak MF. Factors affecting neurological outcome in traumatic conus medullaris and cauda equina injuries. Neurosurg Focus [Internet]. 2008;25(5):E7. Available from:
  14. Pryle BJ, Carter JA, Cadoux-Hudson T. Delayed paraplegia following spinal anaesthesia. Anaesthesia [Internet]. 1996;51(3):263–5. Available from:
  15. Ahmad FU, Pandey P, Sharma BS, Garg A. Foot drop after spinal anesthesia in a patient with a low-lying cord. Int J Obstet Anesth [Internet]. 2006;15(3):233–6. Available from:
  16. Wenger M, Hauswirth CB, Brodhage RP. Undiagnosed adult diastematomyelia associated with neurological symptoms following spinal anaesthesia. Anaesthesia [Internet]. 2001;56(8):764–7. Available from:
  17. Absalom AR, Martinelli G, Scott NB. Spinal cord injury caused by direct damage by local anaesthetic infiltration needle. Br J Anaesth [Internet]. 2001;87(3):512–5. Available from:
  18. Parry H. Spinal cord damage. Anaesthesia [Internet]. 2001;56(3):290. Available from:
  19. Nurfitriani, Nawawi AM, Yadi DF, Anwary F. Letak Conus Medularis terhadap Vertebra Menggunakan Hasil Pencitraan Magnetic Resonance Imaging di Rumah Sakit Dr. Hasan Sadikin Bandung untuk Anestesi Spinal. J Anestesi Perioper [Internet]. 2014;2(3):208–12. Available from:
  20. Saifuddin A, Burnett SJD, White J. The Variation of Position of the Conus Medullaris in an Adult Population. Spine (Phila Pa 1976) [Internet]. 1998;23(13):1452–6. Available from:
  21. Morimoto T, Sonohata M, Kitajima M, Mawatari M, Konishi H, Otani K, et al. The termination level of the conus medullaris and lumbosacral transitional vertebrae. J Orthop Sci [Internet]. 2013;18(6):878–84. Available from:
  22. Moussallem CD, El Masri H, El-Yahchouchi C, Abou Fakher F, Ibrahim A. Relationship of the lumbar lordosis angle to the level of termination of the conus medullaris and thecal sac. Anat Res Int [Internet]. 2014/07/03. 2014;2014:351769. Available from:
  23. Reimann AF, Anson BJ. Vertebral level of termination of the spinal cord with report of a case of sacral cord. Anat Rec [Internet]. 1944;88(1):127–38. Available from:
  24. Mbaba A, Ogolodom M, Abam R, et al. Magnetic Resonance Imaging Localization of the Vertebral Level of Termination of the Spinal Cord in Adults in Port Harcourt, Rivers State, Nigeria. Arch Med [Internet]. 2020;12(1). Available from:
  25. Kalindemirtas M, Orhan M, Bahsi A, Bahsi I, et al. Examination of the Level of Conus Medullaris Termination Using Magnetic Resonance Imaging. Eur J Ther [Internet]. 2021;27(2):123–34. Available from:
  26. Arai Y, Shitoto K, Takahashi M, Kurosawa H. Magnetic Resonance Imaging findings in a case of intramedullary teratoma of conus medullaris. Internet J Radiol [Internet]. 2009;10(2). Available from:
  27. Binokay F, Seydaoğlu G, Erman T, Akgül E, Biçakci K. Relationship Between the Levels of Normal Conus Medullaris and Body Mass Index in the Turkish Adult Population. Neurosurg Q [Internet]. 2013;23(2):81–4. Available from:
  28. Kershenovich A, Macias OM, Syed F, Davenport C, Moore GJ, Lock JH. Conus Medullaris Level in Vertebral Columns With Lumbosacral Transitional Vertebra. Neurosurgery [Internet]. 2016;78(1):62–70. Available from:
  29. Mourlion T, Nkoó S, Monabang Z. Terminaison du cône médullaire, du sac dural et profondeur du canal vertébral chez le noir Africain. African Journal of Neurological Sciences. 2012; 31(2): 65-78.
  30. Rostamzadeh A, Naleini F, Rostamzadeh O. Variations in Position of Conus Medullaris in Adult Patients. Zahedan J Res Med Sci [Internet]. 2016;In Press(InPress). Available from:
  31. Gatonga P, Ogeng’o JA, Awori KO. Spinal cord termination in adult Africans: Relationship with intercristal line and the transumbilical plane. Clin Anat [Internet]. 2010;23(5):563–5. Available from:
  32. Sevinc O, Is M, Barut C, Eryoruk N, Kiran S, Arifoglu Y. MRI Determination of Conus Medullaris Level in an Adult Population in Turkey. Neuroradiol J [Internet]. 2006;19(3):375–8. Available from:
  33. Demiryürek D, Aydingöz Ü, Akşit MD, Yener N, Geyik PÖ. MR imaging determination of the normal level of conus medullaris. Clin Imaging [Internet]. 2002;26(6):375–7. Available from:
  34. Kwon S, Kim TS, Kim HS, Rhyu IJ. The Tip Level of the Conus Medullaris by Magnetic Resonance Imaging and Cadaver Studies in Korean Adults. Korean J Phys Anthropol [Internet]. 2016;29(2):47. Available from:
  35. Yedavalli V, Jain MS, Das D, Massoud TF. Are high lumbar punctures safe? A magnetic resonance imaging morphometric study of the conus medullaris. Clin Anat [Internet]. 2019;32(5):618–29. Available from:
  36. Mancall EL, Brock DG. Dedication [Internet]. Gray’s Clinical Neuroanatomy: The Anatomic Basis for Clinical Neuroscience. Elsevier; 2011. p. v. Available from:
  37. Gaudet CE. Functional and clinical neuroanatomy: A guide for health care professionals. Appl Neuropsychol Adult [Internet]. 2021;29(6):1689. Available from:
  38. Schwartz ED, Flanders AE. Spinal trauma: imaging, diagnosis, and management: Lippincott Williams & Wilkins; 2007.
  39. Standring S. Gray's anatomy e-book: the anatomical basis of clinical practice: Elsevier Health Sciences; 2021.
  40. Young PA, Young PH, Tolbert DL. Basic clinical neuroscience: Lippincott Williams & Wilkins; 2008.
  41. Champney TH. Essential clinical neuroanatomy: John Wiley & Sons; 2015.
  42. Cramer GD, Darby SA. Preface [Internet]. Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014. p. ix. Available from:
  43. Crossman AR, Neary D. Cranial nerves and cranial nerve nuclei [Internet]. Neuroanatomy. Elsevier; 2010. p. 97–110. Available from:
  44. Jacobson S, Marcus EM, Pugsley S. Neuroanatomy for the Neuroscientist [Internet]. Springer International Publishing; 2018. Available from:
  45. Kaura V, Hopkins PM. Smith & Aitkenhead′s Textbook of Anaesthesia. Br J Anaesth [Internet]. 2015;114(2):353–4. Available from:

How to Cite

Adhiatma, A., Waloejo, C. S. ., Wirabuana, B. ., & Rahardjo, E. . (2022). Variation of conus medullaris location based on magnetic resonance imaging of the lumbar spine in Indonesia: A study at Dr Soetomo General Academic Hospital, Surabaya, Indonesia. Bali Medical Journal, 11(3), 1839–1843.




Search Panel

Aria Adhiatma
Google Scholar
BMJ Journal

Christrijogo Sumartono Waloejo
Google Scholar
BMJ Journal

Belindo Wirabuana
Google Scholar
BMJ Journal

Eddy Rahardjo
Google Scholar
BMJ Journal