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The National Ribat University

Faculty of Graduate Studies and Scientific

Researches

Dimensions of Cervical Spinal Canal and

Vertebral body and Their Relevance in

Clinical Practice

Thesis submitted in partial fulfillment for requirement degree of MSc in clinical

human Anatomy

By:

Moaz Ibrahim Abdallah Mohamed

Supervisor:

Dr: Kamal Eldin Elbadawi Babiker

( 2015)

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بسم هللا الرحمن الرحيم

لال حؼالى :

))لمذ خلمىا اإلوسان ف أحسه حمىم((

صذق هللا الؼظم

( 4ت رلم )سىرة الخه ا

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DEDICATION

To my parents,

My brothers and sisters,

To my teacher

To my friends

To my colleagues

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Acknowledgement

I wish to express my sincere thanks and gratefulness to my

supervisor Dr. Kamal Eldin Elbadawi who have made valuable

suggestions, comments and criticism during the preparation of this

dissertation.

Also I am sincerely indebted to the staff of radiology at the

target hospital for their cooperation and facilitation the collection of

data in the practical part of the study.

Finally I am really grateful to everyone who gave me guidance

and encouragement to complete this thesis.

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الذراسة : مستخلص

: الخلفية السززت الممارست ف و دورهم الؼىمت الشىكت و الفمزاث المىاة أبؼاد

: االهذاف -٣)ع الؼىمت الشىكت والفمزاث لمىاةلصممج الذراست الحالت لمؼزفت الماساث الطبؼت

الؼمز و ه مغ وضغ ٳػخبار للجىس( لذي السىداوه البالغ٥ع

لسج أبؼاد مه مسخشفى الزباط الجامؼ و جمؼج الصىر اٳلشؼاػتالمواد والطرق :

.صىرة شؼاػت ألفزاد سىداوه بالغه ٠١١( ف٥ع -٣المىاة الؼىمت الشىكت )ع

النتائج : اكثز و اضا ا بزادة الؼمزخىالصان حذرج الىسظ السهمالمطز االمام الخلف والمطز

احساػا ف الذكىر مه االواد

الخاتمة : والؼمز، بالجىس خؼلك فما ، الؼىمت الشىكت المىاة و الفمزاث ألطار مماس ف اإلخخالفاث

الممارست إلى باإلضافت السززي الخشزح ػل م ف االػخبار ف حذرس أخذ أن مكه

ت السزز

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Abstract

Background: Dimensions of cervical spinal canal and vertebral body

and their relevance in clinical practice.

Objectives: The present study is designed to identify and

measurements the cervical spinal canal and vertebral body in adult

Sudanese subjects, respective of gender and age.

Material and methods: The cervical MR images were collected from

Ribat University Hospital. The dimensions of the cervical spinal

canal (C3 – C5) of the adult Sudanese population were measured on

82 MR images.

Results: The mid sagittal diameter of the vertebral canal and

anteroposterior diameter the vertebral body diminished with

increasing age in both sexes There was large mid sagittal diameter of

vertebral canal and anteroposterior diameter of vertebral body in male

more than female.

Conclusion:

Detection of the variations in the measurements of the diameters of

the cervical spinal canal and vertebral body, in relation to gender and

age, could have a useful impact both in teaching of clinical anatomy

as well as clinical implications

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List of tables

Table Title page

Table (4-1) Age of subjects 12

Table (4-2) Gender in relation to age 12

Table (4-3) Antero-posterior results. 13

Table (4-4) Mid-sagittal diameters results. 14

Table (4.5) Relation between results and gender 14

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List of figures

Fig. Title Page

4.1 The number of subjects within the study 12

4.2 Relationship between the mid-sagittal diameters and age group 15

4.3 Relationship between the antero-posterior diameters and age

group

16

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Abbreviations

C Cervical vertebra

AP Antero-posterior

MS Mid sagittal

mm Millimeter

cm Centimeter

SD Standard deviation

SPSS Statistical package for social sciences

gr group

year yr

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Contents

I االـــت

Dedication II

Acknowledgement III

Abstract in Arabic

Abstract in English

List of tables

List of Figures

IV

V

VI

VII

Abbreviations VIII

Contents Ix

CHAPTER ONE

1.1 Introduction 1

1.2 Objectives 3

1.2.1 General Objectives 3

1.2.2 Specific Objectives

3

CHAPTER TWO

2. Literature review 4

2.1. Gross anatomy of the spine 4

2.2. Overview of the vertebral column 4

2.3 Spinal Canal 4

2.4 Cervical spinal stenosis 5

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CHAPTER THREE

3. Materials and Methods 6

3.1 Study design

3.2 Study area and duration

3.4 Study population

3.5 Inclusion criteria

3.6 Exclusion criteria

3.7 Data collection :

3.7.1 Instrument and tools

3.7.2 Procedure

3.7.3 Data analysis

3.8 Ethical considerations

6

6

6

6

6

6

7

7

7

7

CHAPTER FOUR

4. Results 8

CHAPTER FIVE

5. Discussion 13

CHAPTER SIX

6. Conclusions and Recommendations 14

6.1. Conclusions.

14

6.2. Recommendations.

15

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CHAPTER SEVEN

7. References. 16

Appendix Questionnaire 17

Introduction

1.1. Introduction

The cervical column extends from the base of the skull

above to the articulations with the first thoracic vertebra below at

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the root of the neck. This is the most mobile region of the column.

In addition, the cervical column houses the spinal cord. Thus,

damage to the cord in this region can lead to widespread

neurological disruption and even death. The first and Second

cervical vertebrae have been extensively modified to permit the

movements of nodding and rotation of the head on the neck. The

cervical vertebrae are identified by the presence of foramen

transversaria. There are seven cervical vertebrae out of which the

third to sixth is typical, and the first, second and seventh are

atypical (1)

.

The cervical spinal canal would be stenotic, due to ageing

process or pathological process like tumors or calcification of

posterior longitudinal ligament, causing chronic fatigue and

fibromyalgia syndromes. Also it represents a common site of

spondylosis with subsequent neck pain radiculopathy and

myelopathy. So the knowledge of the measures of cervical spinal

canal is important to differentiate between the normal and stenotic

one (2).

This study is therefore aimed at comprehensive

determination of the dimensions of the cervical spinal canal and

vertebral body radiograph. In order to establish clear anatomical

guide lines for both anatomists and clinicians.

The exact dimensions of cervical vertebral body and spinal canal

are an important consideration in the diagnosis, prognosis and

treatment of diseases related to cervical spine and spinal cord, such

as spinal stenosis and intraspinal tumours (3)

.

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1.2. Objectives:

1.2.1. General Objectives:

To study the dimensions of cervical spinal canal and vertebral

body and their relevance in clinical practice

1.2.2. Specific Objectives:

1. Determine the mid sagittal diameter of the cervical spinal canal

in adult Sudanese people radiologically.

2. Determine the anteroposterior diameter of cervical vertebral

body

3. Determine the relation between mid sagittal diameter of the

cervical spinal canal and anteroposterior diameter of cervical

vertebral body

4. Relation of mid sagittal diameter of the cervical spinal canal and

anteroposterior diameter of cervical vertebral body to the age

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Literature Review

2.1. Gross anatomy of spine

Understanding the detailed anatomy of the vertebral column is

essential for interpreting the normal features, and using best way for

measurements the spinal canal dimensions.

2.2. Overview of the vertebral column:

There are normally 32-34 vertebrae in the adult column, of which

five are fused together to form the sacrum and three to five fused to

form the coccyx, each presacral segment (except the first two cervical)

is separated from its neighbor by a fibrocartilaginous intervertebral

disc (4)

.

The thoracic segment constitutes approximately half the length of

the entire free column, the lumbar column approximately one-third and

the cervical region approximately one-fifth or one-sixth. It is important

to note that the proportions are significantly different in the newborn,

with the cervical segment constituting approximately one-quarter of

the free column, the thoracic region approximately a half and the

lumbar around one-quarter (5)

.

2.3. Spinal Canal

The cervical vertebral canal is smooth-walled tubular space

formed by vertebral foramina of the seven cervical vertebrae which

lying one above the other. Its anterior boundaries are the bodies of

vertebrae, intervertebral discs and the posterior longitudinal ligaments.

Posteriorly the canal bounded by the vertebral lamina and ligaments

flava. While at sides the pedicles of vertebrae form the lateral

boundaries. It protects the cervical part of spinal cord which is cut by

the dens of axis during hanging (6)

.

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Normally the cervical canal measurement ranges from 12 – 14

mm for AP diameter (from the back of vertebral body to the interlaminar

junction posteriorly (7)

.

2.4. Cervical spinal stenosis:

Cervical spinal stenosis is the narrowing of the cervical spinal

canal due to pathology. Stenosis may occur for various reasons including

degenerative changes in the vertebra or intervertebral disc, trauma,

ossification of the posterior longitudinal ligament, and cervical

spondylosis. (3)

Cervical spinal stenosis is a pathological condition in which the

cervical spinal canal becomes narrow because of various predisposing

factors. The clinical importance of identifying spinal stenosis is outlined

by its occurrence amongst older individuals and the prevalence of painful

symptoms associated with this condition. (8)

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Materials and Methods

3.1. Study design:

This is an observational analytical cross-sectional study

3.2. Study area and duration:

The research was conducted at Ribat National Hospital –

Khartoum –Sudan - 2015

3.4. Study population: 82 MR images were studied (55 female

and 27 male) patients who were referred for cervical radiograph.

3.5. Inclusion criteria:-

o Free of major illnesses.

o No history of neck trauma that may affect the cervical

spinal canal.

o No history of cervical vertebrae fracture.

o Adult Sudanese patients only.

3.6. Exclusion criteria:

o Spinal abnormalities.

o Bone pathology.

o History of cervical trauma or surgery.

3.7. Data collection:

3.7.1. Instrument and tools:

All the cervical MR images were measured in axial position

for each vertebra separately. The software was designed

specifically to analyse and give accurate measurements.

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3.7.2. Procedure:

Measurements were taken at the 3rd, 4th and 5th cervical vertebrae

The following diameters were estimated:

1. Mid sagittal diameter of vertebral canal (A).

2. Anteroposterior diameter of vertebral body (B).

After opening the files with its program and selecting the

slide of interest, the distance between the various points were

measured by selecting the “measure distance between two points”

button and then clicking with the mouse pointer on the first point

(e.g. midpoint on the posterior surface of the vertebral body)

followed directly by clicking on the second point The distance

between the two points is automatically calculated by the

software and displayed directly on the slide.

3.7.3 Data analysis:

Statistical analysis of measurements was performed by using

SPSS.

3.8 Ethical Considerations:

Ethical clearance will be obtained from the authorities of the

faculty of graduate studies of the National Ribat University

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Results

Total of the 82 axial cervical MR images used respectively in this study fig

(4.1):

Fig (4.1): The subjects within the study

4.1. Age:

The age of the participants included in this study ranged from 19 to 77

yrs with means of 4.593 cm and SD 1.308 cm. Table (4.1):

Table (4.1): Age

Female 55

Male 27

Number of subjects

N Minimum yrs Maximum yrs Mean SD

subjects 82 19 77 4.593 1.308

Age group Males (n=) Females (n=)

20

4.2. Gender:

The population was divided into males and females (27 and 55

respectively).

Table (4.2): Gender in relation to age.

4.3. Results of the dimensions:

Two diameters were taken anteroposterior and mid sagittal.

4.3.1 Anteroposterior diameter results:

At C3 in 47 of 82 patients the AP diameter canals were ranging

from 0.95 – 1.57 cm, with mean of 1.227 cm and SD of 0.154 cm. Also at

C4 in 79 patients with mean 1.225 cm and SD 0.1572 cm. at C5 in 72

patients ranging from 0.95 – 1.64 cm, with mean 1.256 and SD of 0.141.

Table (4.3):

Table (4.3): Antro-posterior results

gr1( 15 – 35 years ) 4 10

gr2( 36 – 50 years ) 15 20

gr3( 51 year and more ) 8 25

SD Mean Maximum(mm) Minimum(mm) N AP - diameter

0.14064 1.2560 1.64` 0.92 72 C5

0.15728 1.2254 1.58 0.70 79 C4

0.15435 1.2272 1.57 .95 47 C3

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4.3.2 Mid Sagittal diameter results:

Mid-sagittal diameters of 72 subjects at C5 were ranging from

1.63–3.17 cm, with mean of 2.1976 cm and SD of 0.29436 cm. Also at

C4 in 79 subjects mid-sagittal diameter ranging from 1.50 to 2.78 cm,

mean was 2.1397 cm and SD 0.24331 cm.The C3 canal ranging from

1.09 – 2.90 cm, with mean 2.0653 cm and SD of 0.30999 cm. Table (4.4):

Table (4.4): Mid sagittal diameter results.

SD Mean Maximum Minimum N MS diameter

0.29436 2.1976 3.17 1.63 72 C5

0.24331 2.1397 2.78 1.50 79 C4

0.30999 2.0653 2.90 1.09 47 C3

4.4. Relation between gender and diameters:

The relation between gender and diameter was studied and found

that in 24 males, the C5 MS diameter mean was 2.34 cm with SD of

0.329 cm.and in 48 females the mean was 2.122 cm with SD of 0.245 cm.

Regarding the C4 in 24 male and 55 female the mean and SD

were (2.223 – 0.251 cm) (2.103 - 0.232 cm) respectively. Also the mean

and SD of the canal at C3 in male and female was (2.254 – 0.317 cm),

(1.976 – 0.267 cm) Table (4.5).

The average antero-posterior diameter (and SD) of the canals at

C3,C4 and C5 was 1.2368 cm (range from 1.2158 to 1.2585 cm). The

average canal diameter in the female was 1.235 cm, and in the male was

1.238 cm. Table (4.5)

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4.5. Relation between age and diameters:

The results of measurements in fig 2-3 represent the relations

between age and cervical canal dimensions, we found that the ms

diameter at C5 the means was 2.200 cm at gr 1 (15 – 35 years) , 2.228 cm

at gr 2 (36 – 50 years) and 2.1684 at gr 3 (51 years and more) Fig (4.2).

1.8

1.85

1.9

1.95

2

2.05

2.1

2.15

2.2

2.25

Axi

s Ti

tle

C3/MS C4/MS C5 / MS

Relationship between MS diameter and age

groups gr1( 15 – 35 years ) gr2( 36 – 50 years ) gr3( 51 year and more )

24 2.3487 .32968

48 2.1221 .24538

24 2.2238 .25125

55 2.1031 .23262

15 2.2547 .31740

32 1.9766 .26761

24 1.2508 .15117

48 1.2585 .13666

24 1.2158 .13539

55 1.2296 .16693

15 1.2493 .19311

32 1.2169 .13477

Sex

male

female

male

female

male

female

male

female

male

female

male

female

C5 mid-sagittal

C4 mid-sagittal

C3 mid-sagittal

C5 Anteroposterior

C4 Anteroposterior

C3 Anteroposterior

N Mean SD Diameter

Table (4.5): Relation between: diameters and gender

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Fig (4.2): Relationship between MS- diameters and age groups

Regarding the MS dimensions at C4 the means was 2.1223- 2.1539-

2.132 cm at gr 1 (15 – 35 years), gr 2 (36 – 50 years) and gr 3 (51 years

and more) respectively

Variable means at C3 level was 2.1400 cm at gr 1 (15 – 35 years),

2.114 cm at gr 2 (36 – 50 years) and 1.963 cm at gr3 (51 years and more)

Fig (4.3).

Fig (4.3): Relationship between AP- diameters and age groups

1.14

1.16

1.18

1.2

1.22

1.24

1.26

1.28

1.3

1.32

C5/AP C4/AP C3/AP

Relationship between AP - diameters and age

groups

gr1( 15 – 35 years ) gr2( 36 – 50 years ) gr3( 51 year and more )

24

Discussion

The main objective of this study was to determine, the diameters of

the cervical spinal canal in the adult Sudanese population.

A correlation has now been established between the gender and age

related to differences in the diameter of the canal.

The current study, found that the average MS canal diameter from C3

to C5 was (12.37 ± 1.13 mm). The mid-sagittal spinal canal was widest at

C5 level more than C3 and C4. The average mid-sagittal diameter was

21.3 ± 2.79 mm.

The AP diameter of C3, C4, and C5 in males (12.3 mm) was slightly

wider than in females (12.2 mm). The MS diameter of C3, C4, and C5 in

males (22.7 mm) was wider than in females (20.6 mm). The AP and MS

diameters diminished with increasing age in both sexes.

This study has shown that both age and gender have to be considered

when diagnosing cervical spinal stenosis within this population group,

hence the need for clear and reliable dimensional guidelines.

In comparison, these results are similar to international results

including those of American and South African.

The current study has shown that the MS diameter of the cervical

spinal canal in the adult Sudanese population is consistently smaller than

that of the black American Population (9)

. This occurs across all the

vertebrae (C3 to C5) by a value of more than 1.5 mm and even when

considering the SD of their study, the adult Sudanese population is still

below or at their lower limit. The cervical region of the adult Sudanese

population proved to have approximately similar dimensions to the South

African black population (10).

25

Conclusions and Recommendations

6.1. Conclusion:

This research studied the dimensions of the cervical vertebra (C3,

C4, and C5) at the Ribat National Hospital.

Detection of the variations in the measurements of the diameters of

the cervical spinal canal and vertebral body, in relation to gender and age,

could have a useful impact both in teaching of clinical anatomy as well as

clinical implications.

The conclusion of the study :

o There was large MS diameter of vertebral canal and AP diameter

of vertebral body in male more than female.

o The MS diameter of vertebral canal and AP diameter of vertebral

body diminished with increasing age in both sexes.

o The AP diameter of less than 12.3 mm may be associated with an

increased cervical spinal stenosis.

26

6.2. Recommendation:

o More studies are needed to verify the clinical implications of

cervical spinal canal diameters.

o This study has shown that both age and gender have to be

considered when diagnosing cervical spinal stenosis within this

population group, hence the need for clear and reliable dimensional

guidelines.

27

References

1. Gadow, H.F. The Evolution of the Vertebral Column. Acontribution

to the study of vertebrate phylogeny (J.F. Gaskell and H.L.L.H. Green,

Eds). Cambridge: Cambridge University Press. 1933.

2. Ratliff JK, Cooper PR. Cervical laminoplasty: a critical review. J

Neurosurg. 2003; 98: 230-238.

3. Satomi K, Ogawa J, Ishii Y, Hirabayashi K. Short-term complications

and long-term results of expansive open-door laminoplasty for cervical

stenotic myelopathy. Spine J. 2001; 1 (1):26-30.

4. Murone I. The importance of the sagittal diameter of the cervical spinal

canal in relation to spondylosis and myelopathy. J Bone Joint Surgery.

1974; 56-B : 30-36.

5. Nakstad P. Myelographic findings in cervical spines without degenerative

changes. J N.1987; 29: 256-258.

6. Tierney RT, et al. Cervical spine stenosis measures in normal subjects. J

of athletic traing. 2002;37 (2): 190-193.

7. Sasaki T, Kadoya S, Iizuka H. Roentgenological study of the sagittal

diameter of the cervical spinal canal in normal adult Japanese. Neurol

Med Chir (Tokyo). 1998; 38/(2): 83-88.

8. Schneider R, Reifel E, Crisler H, Oosterbaan B. Serious and fatal

football injuries involving the head and spinal cord. JAMA. 1961;177 :362-

367.

9. Francis C. Dimensions of the cervical vertebrae. Anat Rec 1955; 122:

603-609.

10. Tossel G. Dimension of the cervical spinal canal in the South Africa

population .niversity of Pretoria,(South Africa) 2005-2007

28

APPENDIX

Questionnare

The National Ribat University

Faculty of Graduate Studies and Scientific Researches

Dimensions of Cervical Spinal Canal and Vertebral body and

Their Relevance in Clinical Practice

Index number: ………………………………….

Age:

Sex: Male Female

History of cervical vertebrae fractures: Yes No

History of bone disease or skeletal deformity: Yes

No

Hospital

- The National Ribat University Hospital

- niversity Hospital

Measurements of cervical spinal canal at…

Mid-sagittal diameter Antero-posterior diameter Vertebral number

C3

C4

29

C5