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The Relationship Between Disc Degeneration and Morphologic Changes in the Intervertebral Foramen of the Cervical Spine: a Cadaveric MRI and CT Study

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The Relationship Between Disc Degeneration and Morphologic Changes in the Intervertebral Foramen of the Cervical Spine: a Cadaveric MRI and CT Study J Korean Med Sci 2004; 19: 101-6 Copyright � The Korean Academy ISSN 1011-8934 of Medical Sciences The Relationship between Disc Degeneration and Morphologic Changes in the Intervertebral Foramen of the Cervical Spine: A Cadaveric MRI and CT Study A cadaveric study was performed to investigate the relationship between disc degen- Hong Moon Sohn, Jae Won You, eration and morphological changes in the intervertebral foramen of cervical spine, Jun Young Lee including the effect on the nerve root. Seven fresh frozen human cadavers were Department of Orthopaedic Surgery, Chosun University dissected from C1 to T1, preserving the ligaments, capsules, intervertebral disc and Hospital, Gwangju, Korea the neural structures. The specimens were scanned with MRI and then scanned through CT scan in the upright position. Direct mid-sagittal and 45 degree oblique images were obtained to measure the dimension of the intervertebral disc height, foraminal height, width, area and segmental angles. Disc degeneration was inversely Received : 16 July 2003 correlated with disc height. There was a significant correlation between disc degen- Accepted : 24 September 2003 eration and foraminal width (p<0.005) and foraminal area (p< 0.05), but not with foram- inal height. Disc height was correlated with foraminal width but not with height. The segmental angles were decreased more in advanced degenerated discs. There was a correlation between nerve root compression and decreased foraminal width and area (p<0.005). This information and critical dimensions of the intervertebral foramen Address for correspondence for nerve root compression should help in the diagnosis of foraminal stenosis of the Jae Won You, M.D. Department of Orthopaedic Surgery, Chosun University cervical spine in patients presenting with cervical spondylosis and radiculopathy. Hospital, 588 Seosuk-dong, Dong-gu, Gwangju 501-717, Korea Key Words : Cervical Vertebrae; Intervertebral Disk; Magnetic Resonance Imaging; Tomography, X-Ray Tel : +82.62-220-3147, Fax : +82.62-226-3379 Computed E-mail: [email protected] INTRODUCTION ing foraminal stenosis remains the subject of data. Magnetic resonance imaging (MRI) is considered as the gold standard Degenerative changes in the cervical spine are an inevitable for soft tissue pathology, while computed tomography (CT) response to the aging process. Impairment of cervical nerve is still utilized for bony abnormalities. roots may result from instability, disc degeneration, hernia- The purpose of this study was to investigate the anatomic tion or spinal stenosis (1). In recent years, spinal stenosis has changes in intervertebral foramen and nerve root compres- been understood better with respect to its clinical signs and sion with degenerative changes of cervical spine in neutral symptoms, pathophysiology, pathoanatomy and treatment. position using both CT and MRI. Kirkaldy-Willis et al. (2) studied the spectrum of pathologic change in spinal stenosis. The three-joint complex, includ- ing the two posterior joints and the disc, is involved in the MATERIALS AND METHODS pathogenesis. Degenerative changes of the three-joint com- plex occur concurrently and result in instabilities, stenosis Seven fresh cadavers (4 males, 3 females) with ages from and even deformities. 44 to 85 yr (mean=65.3) were used in this study. To rule out In foraminal stenosis, the nerve root can be impinged in any gross pathology aside from cervical spondylosis, plain cephalad/caudad or anterior/posterior direction. Foraminal radiography were taken and analyzed. The extraneous soft nerve root compression can occur secondarily to subluxation tissues were removed carefully so that the ligaments, facet of the superior articular facet, a laterally-herniated disc or capsule and disc remained intact. And then, the cervical spines osteophyte from the posterolateral part of the vertebral body were removed with saw and osteotome, and C1-T1 motion (3). Extensive research has been conducted to investigate the segments were obtained. Extracted cervical spines were atta- intervertebral foramen in the lumbar spine (4-7); however, ched to base molds with resin in the erect position. The motion there is limited data related to the cervical region. segments were frozen rapidly with liquid nitrogen, sealed in The choice of imaging modality most appropriate for detect- plastic bags to prevent dehydration and stored frozen in the 101 102 H.M. Sohn, J.W. You, J.Y. Lee A B Fig. 1. (A) T1-weighted (500/16), 45 degree oblique projections of magnetic resonance imaging of the cervical spine, 1.0 mm slice thick- ness. (B) MRI shows decreased width and area at C5-6 intervertebral foramen (arrow), but relative conservation of foraminal height. 5 7 1 2 3 4 6 8 9 10 11 Fig. 2. Parasagittal oblique plane CT images of the cervical spine. Fig. 3. Diagram showing the sagittal parameters of measurement. 1. Anterior disc height, 2. Midpoint disc height, 3. Posterior disc freezer at -20℃. height, 4. Posterior bulging of disc, 5. Distance of spur, 6. Segmental Total 35 motion segments from C2 to C7 were studied. angle of body, 7. Vertebral body translation, 8. Foraminal height, 9. Using a 1.5 T Signa scanner (GE Medical Systems, Milwau- Middle foraminal width, 10. Foraminal area, 11. Nerve root condition. kee, WI, U.S.A.), sagittal images on T1 (TR: 500 ms, TE: 40 ms, FOV: 16×16 cm) and T2 (TR: 4,000 ms, TE: 90 ms, the head was absent. The medial edge of the foramen was iden- FOV: 16×16 cm) image condition were acquired to allow tified and several images were taken progressing laterally thro- for measurement of disc degeneration. Criteria by Frymoyer ugh the foramen in 45 degree oblique projections (TR: 500 and Gordon (8) were used in this study to clarify the degen- ms, TE: 16 ms, FOV: 16×16 cm, 1.0 mm slice thickness) eration of disc. The specimens were scanned in an erect posi- (Fig. 1). The image included the medial margin of each pedi- tion to make a lordotic curve of cervical spine, even though cle, the isthmus of the foramen, and the lateral edge of the Disc Degeneration and Anatomical Changes of Cervical Spine 103 foramen and vertebral artery. was outlined by the facet joint, the 2 pedicles, the vertebral Nerve root compression was considered to be present when body and the posterior border of the disc was computed using there was contact between the nerve root and adjacent tissue, National Institutes of Health image program software (Scion and when there was deformation of the root. The appearance image, Scion Corporation, Frederick, MD, U.S.A.). All of the of the nerve was graded as normal, contacted or deformed by measurements were made independently by 3 investigators. the bony margins of the foramen by the author. The measurements were repeated twice and took the mean The frozen cervical motion segments were imaged in the value to reduce the errors of measurements. The differences direct sagittal and oblique projections in a CT scanner (Gen- between the measurements of the groups at the different levels eral Electric Medical Systems High-speed Advantage 9800; were analyzed by ANOVA, and regression analysis was per- Milwaukee, WI, U.S.A.) using 120 kV, 200 mA and 1 mm formed to determine any correlation between each parameters. slice thickness (Fig. 2). The CT gantry was oriented identi- cally at each time. The midsagittal CT images and parasagit- tal oblique plane CT images in the middle of the pedicle were RESULTS analyzed. A total of 8 parameters were measured on the midsagittal In terms of disc degeneration, 0% had grade I, 8.6% had and oblique plane CT images, including the disc height (ante- grade II, 31.4% had grade III, 17.1% had grade IV and 42.9% rior, mid-point, and posterior), foraminal height, foraminal had grade V according to criteria by Frymoyer et al. because middle width, posterior bulging of the intervertebral disc, of these cadavers are old aged group (Table 1). Disc degener- distances of the posterior osteophyte from the endplate of ation was inversely correlated with disc height (r=0.714 for the vertebral body, segmental angulation of vertebral body, middle height, r=0.677 for anterior height, r=0.578 for pos- vertebral body translation and the cross sectional area of the terior height). It meant that if disc degeneration was more foramen (Fig. 3). The cross sectional area of the foramen, which severe, disc space was more narrowed. There was a significant correlation between disc degeneration and foraminal width Table 1. Incidence of disc degeneration (p<0.005) and foraminal area (p<0.05), but not with foram- Level/Grade*1345 2 inal height. The segmental angles were decreased in more advanced C2-3 1 5 1 degenerated disc and there was no statistical significance be- C3-4 2 1 1 3 tween segmental angles and other parameters. C4-5 4 3 C5-6 3 4 There was a significant correlation between spur formation C6-7 1 2 4 and disc degeneration (p<0.005) and foraminal area (p<0.005) 0311615 (Table 2). Table 3. Incidence of nerve root condition *Criteria by Frymoyer and Gordon (Ref. 8). Level/R.C* Normal Rt/Lt Contacted Rt/Lt Deformed Rt/Lt Table 2. Values for midsagittal parameters according to the de- generation C2-3 5/4 1/1 1/2 C3-4 1/1 2/0 4/6 Parameter/Grade* 2 3 4 5 C4-5 2/0 1/1 4/6 C5-6 1/0 1/1 5/6 Mid. disc 5.17±0.65 5.76±0.85 5.46±0.61 3.02±1.07 C6-7 1/1 2/3 4/3 height (mm) Spur (mm) 0.59±0.52 0.82±0.47 1.44±1.37 1.86±0.97 10/6 7/6 18/23 Disc bulging 0.56±0.12 1.31±0.81 1.83±0.97 1.63±0.86 *R.C, Root Condition; Rt, right; Lt, left.
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