Radiological determination of safe and adequate corpectomy limits in the cervical region
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2019
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Annals of Medical Research
DOI: 10.5455/annalsmedres.2019.01.032 2019;26(5):854-8
Original Article
Radiological determination of safe and adequate
corpectomy limits in the cervical region
Salim Senturk
Koc University Hospital Department of Neurosurgery, Istanbul, Turkey
Copyright © 2019 by authors and Annals of Medical Research Publishing Inc.
Abstract
Aim: This manuscript aims to display the relationship between the vertebral artery and its surrounding structures to maintain safe
and effective corpectomy during anterior C4, C5, and C6 decompressive surgery.
Material and Methods: Fifty patients who applied to the emergency department and received a cervical computed tomography
(CT) scan were included, and their C4, C5, and C6 vertebrae margins were measured. The following distances were measured: the
distance between the medial wall of the vertebral foramen and lateral border of the anterior arch of the vertebral corpus, the distance
between the junction of the corpus-the pedicle and inferior border of the vertebral foramen, the distance between the medial border
of the vertebral foramen and longus colli muscles, the distance between each vertebral foramen, and the bipedicular distance.
Results: Fifty patients (22 females and 28 males) were assessed in this study. The female and male populations had mean ages of
52.4 and 53.9 years, respectively. All measurements were higher in the lower vertebrae than those in the upper vertebrae. Also all
these measurements were found higher in males than females. The following results were reported: a value: C4, 4.1/4.3 (F/M); C5,
4.6/4.9; and C6, 5/5.2 mm; b value: C4, 4.5/4.7; C5, 4.8/5.1; and C6, 5.1/5.5 mm; c value: C4, 8.6/9; C5, 9/9.6; and C6, 9.3/10.1 mm; d
value: C4, 23.1/24; C5, 23.9/25.2; and C6, 24.5/25.5 mm; e value: C4, 19.3/20.4; C5, 20/21; and C6, 20.5/21.7 mm.
Conclusion: The Distances between the vertebral artery and the surrounding structures and muscles will provide the surgeon a safer
working during anterior corpectomy surgery. These parameters should be taken into consideration during anterior corpectomy to
obtain more secure and effective decompression.
Keywords: Vertebral Artery Injury; Cervical Corpectomy; Vertebral foramen.
Received: 19.01.2019 Accepted: 28.02.2019 Available online: 14.03.2019
Corresponding Author: Salim Senturk, Koc University Hospital Department of Neurosurgery, Istanbul, Turkey
E-mail: senturksalim@gmail.com
854
INTRODUCTION
The anterior cervical discectomy and fusion approach
was described by Smith and Cloward (1.2). Today,
although many modified techniques have been added,
mainly anterior corpectomy and fusion, anterior cervical
discectomy and fusion, multilevel oblique corpectomy
without fusion, cervical arthroplasty techniques are used
as an anterior approach to the cervical region. The anterior
approach techniques are used in patients requiring
anterior decompression of the spinal cord, such as cervical
disc herniation, ossification of the posterior longitudinal
ligament (PLLO), cervical spondylotic myelopathy (CSM),
spinal tumors and cervical dislocations. Using these
techniques, cervical alignment can be restored along
with the decompression of spinal cord and spinal nerve
(3,4). However, in some cases, complications such as
dysphagia, recurrent laryngeal nerve damage, dura mater
injury, root injury, wound infection, graft dislocation and
vertebral artery injury may occur. These conditions may
cause neurological deficits, prolonged hospital stay,
increased cost and deaths (5,6,7). One of the important
causes of mortality is the vertebral artery injury. Although
the incidence of vertebral artery injury is not exactly
known, the reported rates range between 0.07% and
1.4% (8,9,10,11). Vertebral artery injury may sometimes
be asymptomatic, while pseudo-aneurysms can cause
neurological deficit, late-onset bleeding, infarction and
death (12). In some cases, decompression can be done
inadequately with the concern of arterial injury. In this
study, we performed some measurements that would
allow safe and sufficient decompression at C4, C5, C6
levels by precisely determining the localization of the
vertebral artery during an anterior approach.
MATERIAL and METHODS
Cervical CT images of consecutive patients who
Ann Med Res 2019;26(5):854-8
presented to the Koc University Hospital emergency clinic
were examined. Computed tomography scans (Siemens,
Munich, Germany) were all acquired in an axial plane
using a standardized protocol, with post-acquisition
reconstructed coro¬nal and sagittal planes. All images
were reviewed on a PACS workstation (General Electric
Healthcare, Little Chalfont, United Kingdom).
For each of the C4, C5 and C6 vertebrae of the patients,
5 different measurements were made and the averages
were obtained. The measurements were conducted on
axial cervical CT images of the patients. Patients over the
age of 18 years with no history of cervical surgery or a
history of an infection, fracture or tumor in the cervical
vertebrae were included in the study.
In tomography images, the following measurements were
made for each vertebra and the average values were
obtained;
a: The distance between the medial wall of the vertebral
foramen and the lateral border of the anterior arch of the
vertebral corpus (Figure 1. Red line),
b: The distance between junction of the corpus-the
pedicle and the inferior wall of the vertebral foramen
(Figure 2. Red line))
c: The distance between the medial wall of foramen and
the longus colli muscle (Figure 3. Red line). Soft tissue
density was also examined since muscle tissue was
evaluated.
d: The distance between the two vertebral foramina
(Figure 4. Red line)
e: The bipedicular distance (Figure 4. Green line)
This research is a cross-sectional study. Descriptive
statistical methods were used in data analysis. SPSS 16.0
program was used in the analyzes.
Figure 1. The distance between the medial wall of the vertebral
foramen and the lateral border of the anterior arch (Red line on
the picture)
Figure 2. The distance between junction of the corpus-the pedicle
and the inferior wall of the vertebral foramen (Red line on the picture)
Figure 3. The distance between the medial wall of foramen and
the longus colli (Red line on the picture)
Figure 4. The distance between the two vertebral foramina (Red line
on the pictıure) e:The bipedicular distance (Green line on the picture)
855
Ann Med Res 2019;26(5):854-8
RESULTS
A total of 50 patients (22 female and 28 male) were
studied. The mean age was 52.4 years in females with an
age range of 21-80 years and the mean age of males was
53.9 years with an age range of 40-73 years (Table 1).
All values were higher in males than in females and in the
lower vertebral bodies than in the upper vertebral bodies
(Table 2, 3, 4).
The A value was measured as 4.1/4.3mm (F/M) for C4,
4.6/4.9mm for C5 and 5/5.2mm for C6 (Table 2, 3, 4).
The B value was measured as 4.5/4.7mm for C4,
4.8/5.1mm for C5 and 5.1/5.5mm for C6 (Table 2, 3, 4).
The C value was measured as 8.6/9mm for C4, 9/9.6mm
for C5, and 9.3/10.1mm for C6 (Table 2, 3, 4).
The D value was measured as 23.1/24mm for C4,
23.9/25.2mm for C5 and 24.5/25.5mm for C6 (Table 2, 3,
4).
The E value was measured as 19.3/20.4mm for C4,
20/21mm for C5 and 20.5/21.7mm for C6 (Table 2, 3, 4).
Table 1. Man and woman age distrubition
Woman
N Minimum Maximum Mean Std. Deviation
Age 28 21.00 80.00 52.4286 13.31785
Man
N Minimum Maximum Mean Std. Deviation
Age 22 40.00 73.00 53.9091 9.94705
Table 2 . Values for C4 vertebrae
C4 Woman
N Minimum Maximum Mean Std. Deviation
a 28 3.30 5.80 4.1379 63075
b 28 2.90 6.30 4.5089 74673
c 28 7.10 9.90 8.6557 82090
d 28 17.20 27.00 23.1821 2.12795
e 28 13.90 23.20 19.3536 2.22735
C4 Man
N Minimum Maximum Mean Std. Deviation
a 22 3.40 5.90 4.3909 75824
b 22 3.40 6.10 4.7959 81272
c 22 6.90 11.30 9.0500 1.26406
d 22 18.10 29.60 24.4409 2.78596
e 22 15.70 24.80 20.4909 2.22430
Table 3. Values for C5 vertebrae
C5 Woman
N Minimum Maximum Mean Std. Deviation
a 28 3.40 6.10 4.6107 67404
b 28 3.80 6.70 4.8929 70510
c 28 7.30 10.80 9.0143 92124
d 28 17.80 27.50 23.9036 2.12507
e 28 14.10 22.90 20.0321 2.13785
C5 Man
N Minimum Maximum Mean Std. Deviation
a 22 3.70 6.70 4.9209 87530
b 22 3.10 6.90 5.1459 88991
c 22 7.30 12.10 9.6182 1.11211
d 22 18.70 31.30 25.2318 3.04590
e 22 16.10 24.00 21.0091 2.05772
Table 4. Values for C6 vertebrae
C6 Woman
N Minimum Maximum Mean Std. Deviation
a 28 3.60 6.30 5.0086 74226
b 28 4.00 7.30 5.1929 76928
c 28 7.90 11.80 9.3964 98073
d 28 18.10 30.00 24.5429 2.39605
e 28 14.30 23.20 20.5857 2.31416
a = Women
C6 Man
N Minimum Maximum Mean Std. Deviation
a 22 4.10 6.90 5.2368 90312
b 22 3.90 6.70 5.5327 78676
c 22 8.10 12.40 10.1227 1.13218
d 22 19.10 32.00 25.5773 3.00538
e 22 16.40 24.50 21.7682 2.03736
DISCUSSION
There are many anatomical and radiological studies
about cervical vertebrae in the literature. In these studies,
changes in vertebrae according to gender, age and ethnic
origin were revealed (13,14).
A study examining the vertebral corpus and foramen
identified remarkable differences between males and
females (15).
The present study aimed to determine mean values in the
Turkish population. We evaluated mean values separately
for males and females; because of this difference between
males and females has been clearly revealed in literature
(13,15).
Although some differences have been found between
right and left side measurements in a study examining the
vertebral corpus and the uncinated process, it was found
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Ann Med Res 2019;26(5):854-8
that this was not a statistically significant difference (16).
In our study, all measurements were made on the right side
without any discrimination for the left and right sides (for a,
b, c values). In the study, the measurements were made on
the vertebral bodies that are frequently removed through
corpectomy procedure, while no measurement was made
for C7 since vertebral artery enters the transverse foramen
mostly at the level of C6 (17).
Measurements have been made to understand the
relationship of the vertebral artery with the vertebral
corpus and to perform a safe corpectomy. For this
purpose, the A value gives some idea about that what
extent the decompression from medial to lateral can
safely be extended.
It shows, on the axial plane, the distance between the
anterior lateral arch of the corpus anterior and the line
passing along the medial wall of the vertebral foramen
(Figure 1). The longus colli muscle is stripped and the
lateral border of the vertebral corpus can be easily exposed
with a dissector. The vertebral foramen was detected from
this ponit in the 4.1/4.3mm (F/M) lateral of C4, 4.6/4.9 of
C5, and 5/5.2mm of C6. Therefore, when it is proceeded
in the lateral of the vertebral corpus detected with the
dissector, the vertebral foramen still remains distant.
When a limited corpectomy is performed between the
anterior arches of both vertebral bodies, the corpectomy
can be performed without the possibility of interfering with
vertebral artery. However, it should be kept in mind that
there might be anatomical variations. For each patient, the
relationship between the vertebral artery and the corpus
should be reviewed.
The B value was measured as 4.5/4.7mm for C4, 4.8/5.1mm
for C5 and 5.1/5.5mm for C6. The B value indicates the
distance between the pedicle and the vertebral foramen
(Figure 2). During the microdiscectomy, the pedicle is
detected via a dura hook, and the distance from the
vertebral foramen is determined. The measurement of this
distance allows us to remain at a safe distance from the
vertebral artery during discectomy and corpectomy.
The C value was measured as 8.6/9mm for C4, 9/9.6mm
for C5 and 9.3/10.1mm for C6. This value indicates the
distance between the medial wall of the foramen and medial
border of the longus colli the longus colli muscle (Figure
3). The longus colli muscle is visualized radiologically but
it is also inspected macroscopically. In this measurement,
safe distance to the lateral is determined by taking this
muscle as the landmark.
In a study in which vertebral arteries and transverse
foramina were measured, the mean diameter of the
vertebral artery was measured as 13.63mm and the
diameter of transverse foramen was 28.49mm (18).
In a study examining the course of the vertebral artery, it
was determined that the vertebral artery proceeded at the
anterior of the foramen and was adjacent to the lateral
tubercle of the transverse process at the level of C6, while
ascending to the C3 level, it proceeds at the posterior of
the foramen in the transverse foramen (17,19).
Preoperative localization of the vertebral artery at the
target corpectomy level will avoid possible injury to the
vertebral artery.
The D value was measured as 23.1/24mm for C4,
23.9/25.2mm for C5 and 24.5/25.5mm for C6. This value
indicates the distance between the vertebral foramina. In
this way, we learn our safe width during corpectomy.
The E value was measured as 19.3/20.4mm for C4,
20/21mm for C5 and 20.5/21.7mm for C6. This value
shows the distance between the pedicles in the corpus
base (Figure 4). It also indicates the potential width at
the base if maximum decompression was performed,
although this is also dependent on the pathology.
Vertebral artery injury may develop during foraminotomy
or uncovertebral joint resection. Especially when working
in this region, the use of a high-speed drill for lateral
decompression, aggressive discectomy or aggressive bone
decompression, misapplications during decompression
of the spinal canal that lateral aspect of which is invaded
by a tumor or infection can lead to vertebral artery injury
(20.21).
The reoperation rate was reported to be 0.1% due to
insufficient decompression and inability of placing
the graft properly. Good planning of the distance for
corpectomy will allow adequate decompression and
a proper decompression area to allow the graft to be
placed properly (22). This will further reduce graft-related
reoperation rates.
There is a lack of consensus in literature regarding the
width of corpectomy, and it has been reported that 14-
16 mm central decompression is sufficient in a series of
surgical patients with degenerative cervical pathology
(23).
There are authors suggesting that the corpectomy width
above 15 mm increases the likelihood of vertebral artery
injury, and likewise, a width of less than 15 mm reduces
the possibility of C5 paralysis (24).
Knowing the bipedicular distance and knowing the
distance between the transverse foramina will reduce
the likelihood of reoperation due to insufficient
decompression. Considering that the recommended
decompression width in the literature is 15 mm, a value
of 15 mm remains within the safe limits in cases provided
that adequate decompression is achieved.
These values are different for each patient; therefore, it
is important to calculate these values for each patient in
order to perform corpectomy safely.
In addition to these values, the distance between the
anterior surface of the corpus and the spinal cord should
also be calculated. This value gives us an idea of the depth
which we should be more meticulous. The measurements
provide the surgeon with convenience for maximum and
safe decompression.
857
Ann Med Res 2019;26(5):854-8
CONCLUSION
We performed some measurements to reduce the
possibility of a vertebral artery injury during cervical
corpectomy and to avoid insufficient decompression
These values are different for each patient; therefore, it
is important to calculate these values for each patient to
be operated rather than using these averages in order to
perform corpectomy safely. It should be noted that there
will be anatomical variations. We believe that a good
planning and radiological evaluation performed before
every operation will reduce the complication rates.
Competing interests: The authors declare that they have no competing
interest.
Financial Disclosure: There are no financial supports
Ethical approval: Retrospective Study
Salim Senturk ORCID: 0000-0003-0524-9537
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Senturk, S. (2021). Radiological determination of safe and adequate corpectomy limits in the cervical region . Annals of Medical Research
