Inaccurate counting of spinal levels can contribute to adverse patient outcomes. This article described best practices for identification of spinal levels, based on a literature review and discussion. Most importantly, spinal levels should be counted top to bottom and the iliolumbar ligament can be used to identify the L5 level on cross-sectional imaging. Descriptive language for transitional vertebrae can help spine surgeons to identify these levels correctly during surgery and to perform intraoperative imaging studies that allow for visualization of the landmarks needed to accurately determine spinal levels.
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