The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019

Computerized Tomographic Morphometric Analysis of the Cervical Spine



DS Evangelopoulos*, 1, 3, P Kontovazenitis1, S Kouris2, X Zlatidou2, LM Benneker3, JA Vlamis1, DS Korres1, N Efstathopoulos4
1 3rd Orthopaedic Department, University of Athens, KAT hospital, Athens, Greece
2 Radiology Department, KAT Hospital, Athens, Greece
3 Orthopaedic Department, University of Bern, Inselspital, Bern, Switzerland
4 2nd Orthopaedic Department, University of Athens, Konstantopoulion Hospital, Athens, Greece

Abstract

Background:

Detailed knowledge of cervical canal and transverse foramens’ morphometry is critical for understanding the pathology of certain diseases and for proper preoperative planning. Lateral x-rays do not provide the necessary accuracy. A retrospective morphometric study of the cervical canal was performed at the authors’ institution to measure mean dimensions of sagittal canal diameter (SCD), right and left transverse foramens’ sagittal (SFD) and transverse (TFD) diameters and minimum distance between spinal canal and transverse foramens (dSC-TF) for each level of the cervical spine from C1-C7, using computerized tomographic scans, in 100 patients from the archives of the Emergency Room.

Results:

Significant differences for SCD were detected between C1 and the other levels of the cervical spine for both male and female patients. For the transverse foramen, significant differences in sagittal diameters were detected at C3, C4, C5 levels. For transverse diameters, significant differences at C3 and C4 levels. A significant difference of the distance between the transverse spinal foramen and the cervical canal was measured between left and right side at the level of C3. This difference was equally observed to male and female subjects.

Conclusion:

CT scan can replace older conventional radiography techniques by providing more accurate measurements on anatomical elements of the cervical spine that could facilitate diagnosis and preoperative planning, thus avoiding possible trauma to the vertebral arteries during tissue dissection and instrument application.

Keywords: Morphometric analysis, cervical spine, spinal canal, transverse foramen.


Article Information


Identifiers and Pagination:

Year: 2012
Volume: 6
First Page: 250
Last Page: 254
Publisher Id: TOORTHJ-6-250
DOI: 10.2174/1874325001206010250

Article History:

Received Date: 4/12/2011
Revision Received Date: 30/4/2012
Acceptance Date: 2/5/2012
Electronic publication date: 29/6/2012
Collection year: 2012

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© Evangelopoulos et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the 3rd Orthopaedic Department, University of Athens, “KAT Hospital”, 48 Lemesou str. Athens, Greece; Tel: +306932214079; E-mail: ds.evangelopoulos@gmail.com





INTRODUCTION

Spinal stenosis is a major predisposing factor for cervical myelopathy and spinal cord injury and plays a decisive role on the outcome of injury patterns [1 Hukuda S, Kojima Y. Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical of cervical myelopathy in men Spine 2002; 27(3): 250-3.-5 Torg JS, Naranja RJ, Pavlov H, Galinat BJ, Warren R, Stine RA. The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players J Bone Joint Surg Am 1996; 78(9): 1308-4.]. The size of the canal has been reported to function as a diagnostic tool on the development of myelopathy, in patients with degenerative stenosis [3 Murone I. The importance of the sagittal diameters of the cervical spinal canal in relation to spondylosis and myelopathy J Bone Joint Surg Br 1974; 56(1): 30-6., 6 Yue WM, Tan SB, Tan MH, Koh DC, Tan CT. The Torg-Pavlov ratio in cervical spondylotic myelopathy. A comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic nonmyelopathic population Spine 2001; 26(16): 1760-4., 7 Hashimoto I, Tak YK. The true sagittal diameter of the cervical spinal canal and its diagnostic significance in cervical myelopathy J Neurosurg 1977; 47(6): 912-6.].

In the past, several efforts have been conducted to accurately measure cervical spinal canal’s diameter, in patients with degenerative canal stenosis [7 Hashimoto I, Tak YK. The true sagittal diameter of the cervical spinal canal and its diagnostic significance in cervical myelopathy J Neurosurg 1977; 47(6): 912-6.-10 Remes VM, Heinanen MT, Kinnunen JS, Marttinen EJ. Reference values for radiological evaluation of cervical vertebral body shape and spinal canal Pediatr Radiol 2000; 30(3): 190-5.]. Nevertheless, plain x-ray measurements lacked compatibility due to differences in magnification [11 Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method Radiology 1987; 164(3): 771-5.]. Studies using computed tomography have also been performed on the vertebral bodies’ width, the lateral masses, the pedicles and the foramen of C2 nerve root [12 Kwon BK, Song F, Morrison WB, et al. Morphologic evaluation of cervical spine anatomy with computed tomography: anterior cervical plate fixation considerations J Spinal Disord Tech 2004; 17(2): 102-7.-15 Bilge O. An anatomic and morphometric study of C2 nerve root ganglion and its corresponding foramen Spine 2004; 29(5): 495-9.]. Apart from the osseous structures, other anatomical elements of the cervical spine have been analyzed [16 Hong JT, Park DK, Lee MJ, Kim SW, An HS. Anatomical variations of the vertebral artery segment in the lower cervical spine: analysis by three-dimensional computed tomography angiography Spine 2008; 33(22): 2422-6., 17 Albayrak R, Degirmenci B, Acar M, Haktanir A, Colbay M, Yaman M. Doppler sonography evaluation of flow velocity and volume of the extracranial internal carotid and vertebral arteries in healthy adults J Clin Ultrasound 2007; 35(1): 27-33.].

We performed a CT analysis of the cervical spine to provide accurate measurements on sagittal canal diameter (SCD), right and left transverse foramens’ sagittal (SFD) and transverse (TFD) diameters and distance between spinal canal and transverse foramens (dSC-TF) for each level of the cervical spine, from C1-C7. These data could serve as useful tools for preoperative planning, regarding the surgical approach and screw orientation to the cervical spine.

MATERIALS AND METHODS

One hundred patients ≥ 18 years who had cervical spinal multiplanar computed tomography (CT) imaging performed for a variety of reasons were evaluated for this study. Patients were randomly chosen from the authors’ Emergency Room Radiology imaging data bank (level A Trauma Center). Subjects with evidence of infectious, neoplastic, traumatic, or congenital spine anomalies were excluded from the study.

The study group consisted of, 50 males and 50 females. Mean age was 46.73 years (range 20-79). Mean age for males was 48.78 years (range 20-77) and for females 46.59 years (range 26-79) Table 1. CT-scans were performed with the patient supine and the neck at a neutral position. For each level of the cervical spine, axial and sagittal images from C1 to C7 were selected and the following parameters were determined using the measuring tools of the Imaging software: (i) the sagittal canal diameter (SCD) (Fig. 1), (ii) the transverse foramens’ sagittal (SFD) and (iii) transverse (TFD) diameters and (iv) the distance between spinal canal and transverse foramen (dSC-TF) (Fig. 2). The sagittal canal diameters were measured at the midvertebral level where no degenerative changes are to be expected. The data were divided into two size-matched groups: males and females. Statistical analysis was performed using paired t-test.

Table 1

Patients’ Characteristics (Age in Years, Weight in Kgrs and Height in Meters)




Fig. (1)

Sagittal canal diameters (SCD), at the midvertebral level, were measured on the mid-sagittal images from C1 to C7.



Fig. (2)

Transverse foramens sagittal (SFD) and transverse (TFD) diameters (left) as well as the distances of transverse foramens to the spinal canal (dSC-TF, right) were measured on the axial images from C1 to C7.



RESULTS

One hundred cervical spines comprising 700 vertebrae from C1 to C7 were evaluated. The means and standard deviations of the parameters were calculated at each level for male and female patients separately. Male and female SCD, SFD, TFD and dSC-TF values were compared.

Sagittal Canal Diameter (SCD)

For both groups, the widest sagittal canal diameter was measured at C1 and the narrowest at C4. Mean SCD was greater in males than in females (Table 2). However, only at the level of C6, a significant difference between male and female SCD was detected (p=0.005). Significant differences of SCD were also detected between C1 and the other levels of the cervical spine for both male and female patients, as well as between C2-C4 for males and C2-C4, C2-C6 and C3-C4 for females ((p<0.05).

Table 2

Mean ± SD Values for Sagittal Spinal Canal Diameters (SCD). Mean Values were Greater for Males for All the Levels of CS. Only for C6 Level (Bold), a Significant Difference was Detected (p=0.005)




Transverse Foramens’ Sagittal and Transverse Diameter (R/L SFD – R/L TFD)

The narrowest mean R-SFD was detected at C7 and the widest at C1, for both males and females. Similar results were obtained for the L-SFD values. On the contrary, the widest mean R-TFD values were measured at C7 and the narrowest at C1 for both males and females. Similar results were found for the L-TFD values (Table 3). Significant differences for L-SFDs between males and females were detected at C3, C4 and C5 levels (p<0.05). For male patients, significant differences for SFDs were detected between left and right foramen at the levels of C4, C5 and C6 and for females, at the levels C3, C4 and C5 (p<0.05). For TFDs, significant differences between males and females were detected at C3 and C4 levels (p<0.05). Similarly, significant differences were detected between left and right transverse foramen diameters at C3 and C4 levels for male and female patients (p<0.05).

Table 3

Mean ± SD Values for Sagittal & Transverse Left and Right Transverse Foramens Diameters for Male & Female Subjects. Significant Differences (p<0.05) were Detected at C3, C4, C5 and C6 Levels of the Cervical Spine (Bold)




Distance Between Spinal Canal and Transverse Foramens (dSC-TF)

The narrowest mean right distance between Spinal Canal and Transverse Foramens (mean right-dSC-TF) was found at C5 and the widest at C1 for males and at C4 (narrowest space) and C1 (widest space) for females, respectively. Similar results were found for mean left-dSC-TF (Table 4). A significant difference was revealed for both male and female patients between left and right side at the level of C3 (p<0.05). Comparison between males and females demonstrated significant differences at C2, C3 and C4 levels on the left side of the cervical spine (p<0.05), while on the ride side, no significant difference was detected.

Table 4

Mean ± SD Values for the Distance Between Spinal Canal and Transverse Foramens (dSC-TF). Significant Differences (p<0.05) were Detected at C2, C3, C4 Levels of the Cervical Spine (Bold)




DISCUSSION

Degenerative cervical spine diseases narrow spinal canal’s vital space, thus influencing proper function of neural elements at the level of the stenosis. The risk for the onset of neurological symptoms, even with low energy trauma, becomes greater in patients with progressed stenotic changes [9 Tatarek NE. Variation in the human cervical neural canal Spine J 2005; 5(6): 623-31., 10 Remes VM, Heinanen MT, Kinnunen JS, Marttinen EJ. Reference values for radiological evaluation of cervical vertebral body shape and spinal canal Pediatr Radiol 2000; 30(3): 190-5., 18 Debois V, Herz R, Berghmans D, Hermans B, Herregodts P. Soft cervical disc herniation. Influence of cervical spinal canal measurements on development of neurologic symptoms Spine 1999; 24(19): 1996-2002.].

Several radiological techniques have been applied to measure canal’s sagittal diameter and detect a correlation with cervical myelopathy with the aim to establish a potent predicting factor [19 Lim JK, Wong HK. Variation of the cervical spinal Torg ratio with gender and ethnicity Spine J 2004; 4(4): 396-401., 20 Torg JS, Corcoran TA, Thibault LE, et al. Cervical cord neuropraxia: classification, pathomechanics, morbidity and management guidelines J Neurosurg 1997; 87(6): 843-50.]. Application of Torg-Pavlov’s ratio on plain x-rays is a widespread, low cost technique [6 Yue WM, Tan SB, Tan MH, Koh DC, Tan CT. The Torg-Pavlov ratio in cervical spondylotic myelopathy. A comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic nonmyelopathic population Spine 2001; 26(16): 1760-4., 10 Remes VM, Heinanen MT, Kinnunen JS, Marttinen EJ. Reference values for radiological evaluation of cervical vertebral body shape and spinal canal Pediatr Radiol 2000; 30(3): 190-5., 11 Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method Radiology 1987; 164(3): 771-5.]. Herzog et al, evaluating Torg-Pavlov ratio reported a high sensitivity but a poor positive predictive value [21 Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ. Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players. Plain film radiography, multiplanar computed tomography, and magnetic resonance imaging Spine 1991; 16(Suppl 6): S178-86.]. On the other hand, CT-scan and MRI perform accurate measurements on the anatomical structures of the cervical spine, thus avoiding technical errors that could lead to false calculations. At our institution, all patients with head and cervical spine injuries receive a CCT (cranial computed tomography), according to the Canadian CT head rules for patients with minor head injury [22 Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet 2001; 357(9266): 1391-6.].

These results suggest gradual decline of spinal canal sagittal diameters, from C1 to C4. At the level of C5 the sagittal diameter increases and then declines again at the level of C6. The smallest sagittal diameter of the canal was detected at the level of C4. This was observed in both study groups (males, females). Similar findings have been reported by Song et al. in their study on spinal stenosis and neurological outcome in traumatic cervical spine injury [23 Song KJ, Choi BW, Kim SJ, Kim GH, Kim YS, Song JH. The relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury: an analysis using Pavlov’s ratio, spinal cord area and spinal canal area Clin Orthop Surg 2009; 1(1): 11-8.]. However, when comparing these findings to other, more clinically related studies, one must be aware that in case of degenerative changes the smallest sagittal diameter is mostly determined by the presence of osteophytes and therefore not necessarily has to be at the level of the anatomically smallest diameter.

Comparison between mean values of the dimensions of the transverse spinal foramens revealed that sagittal and transverse foramens’ diameters are greater in males than in females, for each level of the cervical spine. Moreover at C1 level, sagittal diameter is greater than the transverse, while for all the other levels of cervical spine (C2-C7) the transverse diameter is greater than the sagittal. This phenomenon was equally detected in the two groups of the study (males, females). The measurements showed that the left spinal foramen was found to be greater than the right one. This difference was equally observed in male and female subjects and for each level of the cervical spine, implicating a larger left-sided vertebral artery and a possible asymmetric blood supply of these arteries. This hypothesis has also been proposed by Duan et al. on their work on vertebral artery course and function at the craniocervical junction [24 Duan S, Lv S, Ye F, Lin Q. Imaging anatomy and variation of vertebral artery and bone structure at craniocervical junction Eur Spine J 2009; 18(8): 1102-8.]. This observation could serve as an important tool for all treating physicians and especially for those performing a surgical approach on the cervical spine since it could provide important data not only for the surgical approach (selection of the side, right or left), but also for the surgical technique (size and orientation of screws) to be applied.

Mean distance of spinal canal to transverse foramens was found to be greater for males than for females. A greater mean distance between spinal canal and transverse foramen was measured on the right side than on the left side. This is in accordance with our results, indicating that the left transverse foramen is bigger than the right one. For male subjects minimum mean dSC-TF was detected at the level of C5 while for female at the level of C4.

In conclusion, CT scan can provide accurate cervical canal measurements that could serve as a useful guide in the determination of the cervical canal stenosis, replacing the old lateral plain x-ray technique. Further studies are required to apply the Torg-Pavlov ratio on the more accurate cervical CT scans. Moreover, our measurements on the transverse foramen diameters may provide important informations to the spinal surgeons on the dimensions of the foramen and on its geometrical changes according to the cervical level, thus facilitating the preoperative planning and avoiding possible trauma to the vertebral arteries during tissue dissection and instrument application.

ACKNOWLEDGEMENT

Declared none.

CONFLICT OF INTEREST

Declared none.

ABBREVIATIONS

CS  = Cervical spine
SC  = Spinal canal
TF  = Transverse foramen
SCD  = Sagittal canal diameter
R/L-SFD  = Right/left transverse foramens’ sagittal diameters
R/L-TFD  = Right/left transverse foramens’ transverse diameters
dSC-TF  = Distance between spinal canal and transverse foramen

REFERENCES

[1] Hukuda S, Kojima Y. Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical of cervical myelopathy in men Spine 2002; 27(3): 250-3.
[2] Tierney RT, Maldjian C, Mattacola CG, Straub SJ, Sitler MR. Cervical spine stenosis measures in normal subjects J Athl Train 2002; 37(2): 190-3.
[3] Murone I. The importance of the sagittal diameters of the cervical spinal canal in relation to spondylosis and myelopathy J Bone Joint Surg Br 1974; 56(1): 30-6.
[4] Stemper BD, Yoganandan N, Pintar FA, et al. Anatomical gender differences in cervical vertebrae of size-matched volunteers Spine 2008; 33(2): E44-9.
[5] Torg JS, Naranja RJ, Pavlov H, Galinat BJ, Warren R, Stine RA. The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players J Bone Joint Surg Am 1996; 78(9): 1308-4.
[6] Yue WM, Tan SB, Tan MH, Koh DC, Tan CT. The Torg-Pavlov ratio in cervical spondylotic myelopathy. A comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic nonmyelopathic population Spine 2001; 26(16): 1760-4.
[7] Hashimoto I, Tak YK. The true sagittal diameter of the cervical spinal canal and its diagnostic significance in cervical myelopathy J Neurosurg 1977; 47(6): 912-6.
[8] Ishikawa M, Matsumoto M, Fujimura Y, Chiba K, Toyama Y. Changes of cervical spinal cord and cervical spinal canal with age in asymptomatic subjects Spinal Cord 2003; 41(3): 159-63.
[9] Tatarek NE. Variation in the human cervical neural canal Spine J 2005; 5(6): 623-31.
[10] Remes VM, Heinanen MT, Kinnunen JS, Marttinen EJ. Reference values for radiological evaluation of cervical vertebral body shape and spinal canal Pediatr Radiol 2000; 30(3): 190-5.
[11] Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method Radiology 1987; 164(3): 771-5.
[12] Kwon BK, Song F, Morrison WB, et al. Morphologic evaluation of cervical spine anatomy with computed tomography: anterior cervical plate fixation considerations J Spinal Disord Tech 2004; 17(2): 102-7.
[13] Abdullah KG, Steinmetz MP, Mroz TE. Morphometric and volumetric analysis of the lateral masses of the lower cervical spine Spine 2009; 34(14): 1476-9.
[14] Rao RD, Marawar SV, Stemper BD, Yoganandan N, Shender BS. Computerized tomographic morphometric analysis of subaxial cervical spine pedicles in young asymptomatic volunteers J Bone Joint Surg Am 2008; 90(9): 1914-21.
[15] Bilge O. An anatomic and morphometric study of C2 nerve root ganglion and its corresponding foramen Spine 2004; 29(5): 495-9.
[16] Hong JT, Park DK, Lee MJ, Kim SW, An HS. Anatomical variations of the vertebral artery segment in the lower cervical spine: analysis by three-dimensional computed tomography angiography Spine 2008; 33(22): 2422-6.
[17] Albayrak R, Degirmenci B, Acar M, Haktanir A, Colbay M, Yaman M. Doppler sonography evaluation of flow velocity and volume of the extracranial internal carotid and vertebral arteries in healthy adults J Clin Ultrasound 2007; 35(1): 27-33.
[18] Debois V, Herz R, Berghmans D, Hermans B, Herregodts P. Soft cervical disc herniation. Influence of cervical spinal canal measurements on development of neurologic symptoms Spine 1999; 24(19): 1996-2002.
[19] Lim JK, Wong HK. Variation of the cervical spinal Torg ratio with gender and ethnicity Spine J 2004; 4(4): 396-401.
[20] Torg JS, Corcoran TA, Thibault LE, et al. Cervical cord neuropraxia: classification, pathomechanics, morbidity and management guidelines J Neurosurg 1997; 87(6): 843-50.
[21] Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ. Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players. Plain film radiography, multiplanar computed tomography, and magnetic resonance imaging Spine 1991; 16(Suppl 6): S178-86.
[22] Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet 2001; 357(9266): 1391-6.
[23] Song KJ, Choi BW, Kim SJ, Kim GH, Kim YS, Song JH. The relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury: an analysis using Pavlov’s ratio, spinal cord area and spinal canal area Clin Orthop Surg 2009; 1(1): 11-8.
[24] Duan S, Lv S, Ye F, Lin Q. Imaging anatomy and variation of vertebral artery and bone structure at craniocervical junction Eur Spine J 2009; 18(8): 1102-8.

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