Keywords

Morphological status; Cervical spine; Patients; Cervical vertebrae

Introduction

The cervical spine consists of seven vertebrae C1-C7 that are the smallest part of the vertebral column. The vertebrae and intervertebral discs create spaces that allow the spinal nerves to exit. The cervical vertebrae, as a group, produce a lordotic curve. This is while the cervical vertebrae have the most morphological features, the cervical vertebrae have several distinctive features compared to the lumbar or thoracic vertebrae, the most noticeable difference being the presence of a foramen in each transverse process (except C7). These transverse foramina enclose the vertebral arteries. Another unique feature of the cervical vertebrae is that they have the highest intervertebral disc height, which increases the range of motion [1]. The spine is also important due to its vital role in protecting the spinal cord and spinal nerve branches, supporting the thorax and abdomen, and enabling flexibility and mobility of the body and neck rotation. Therefore, identifying the pathological processes of the vertebrae largely depends on determining a standard for the vertebrae and their evolutionary and dynamic process [2]. Various factors such as age, sex and ethnicity, trauma, congenital defects and behavioral habits affect the anatomy of the cervical vertebrae [3]. One of the factors affecting the shape and appearance of the cervical spine is the aging process, which ultimately leads to cervical spine instability, disc herniation, spinal stenosis in the vertebral foramen and changes in the vertebral joint level. Another important factor affecting the morphology of the cervical vertebrae in traumatic cases is that in Iran, after cardiovascular diseases, it is the second cause of death. Only 2 to 3 percent of non-penetrating traumas involve cervical injuries, but due to the high mortality rate and complications resulting from it, it is very important. Most cervical fractures occur at two levels. About a third of them occur at the C2 level and half of the injuries occur at the C6 or C7 level. Most fatal cervical spine injuries occur at the upper neck levels, especially at the cranio-cervical C1 or C2 site. Research suggests that mastering the precise anatomy of the cervical spine (C1-C7) and its relationship with the vertebral arteries can significantly reduce unwanted damage to the vital structures of this area. Considering the prevalence of spinal complications and their harmful effects and also the necessity of knowing the factors affecting the morphological status and also due to the lack of accurate and consistent studies that have examined the morphological status of the cervical spine, the aim of the present study was to focus on identifying the factors affecting the morphological status of the cervical spine.

Materials and Methods

This cross-sectional study examined the morphological status of the cervical spine of patients with neck trauma referred to Taleghani Hospital in Kermanshah. The data collection tools in our study included checklists with demographic information and file information. The required sample size was calculated to be 450 patients, which included 302 men and 148 women, who were randomly selected and entered the study according to the date of referral. In this study, the initial CT-scans of the patients were examined and patients with acute or previous cervical fracture were not included in the study. The patients were divided into three age groups of 20-39, 40-59 and over 60 years [4,5]. In this study, the morphological status of the cervical spine of the patients was measured by indices of superior vertebral body wider, superior vertebral body length, inferior vertebral body wider, inferior vertebral body length and also measurements related to the width and height at each disc level (anterior vertebral body high and posterior vertebral body high) and these measurements (superior vertebral foramina wider, superior vertebral foramina length, length of right and left superior facet) were performed in the mid-sagittal plane.

Results

Findings

Out of 450 subjects, about 67% were male and 176 (39.1%) were 20 to 39 years old, 168 (37.3%) were 40 to 59 years old and 106 (23.6%) were over 60 years old. The mean height and BMI of the subjects were 173.51 ± 10.459 and 28.126 ± 3.918, respectively [6].

The results showed that C4, C5 and C7 vertebrae in superior vertebral body wider, C3 and C4 vertebrae in superior vertebral body length, C4 and C5 vertebrae in inferior vertebral body wider, C6 vertebra in anterior vertebral body high, C3 and C4 vertebrae in posterior vertebral body high and C6 and C7 vertebrae in superior vertebral foramina wider had significant differences between men and women (p<0.01) and the mean of these vertebrae (in terms of height, width and length) were higher and wider in men than women (Table 1).

Table 1: Demographic characteristics of patients with morphological problems of the cervical spine (C3-C7).

The results indicated that C3 and C5 vertebrae in superior vertebral body wider, C3 and C4 vertebrae in superior vertebral body length, C4 vertebra in inferior vertebral body wider, C4 and C5 vertebrae in posterior vertebral body high, C6 vertebra in superior vertebral foramina wider and C3 vertebra in superior vertebral foramina length had significant differences among different ages (pË?0.01) and the mean of these vertebrae (in terms of height, width and length) were higher and wider in ages over 60 years than lower ages (Table 2).

Table 2: The relationship between gender and morphological status of the patients.

The results showed that C5 and C6 vertebrae in superior vertebral body wider, C3 and C4 vertebrae in inferior vertebral body length and C5 vertebra in posterior vertebral body high had significant differences among different heights (p<0.01) and the mean of these vertebrae (in terms of height, width and length) were higher and wider in heights over 180 meters than shorter heights (Table 3).

Table 3: Determining the relationship between age and morphological status in the study population.

The results indicated that the vertebrae C3, C4 and C5 in the superior vertebral body width, the vertebra C3 in the superior vertebral body length, the vertebra C3 in the inferior vertebral body width, the vertebra C7 in the inferior vertebral body length, the vertebra C6 in the anterior vertebral body height and the vertebrae C6 and C7 in the posterior vertebral body height had significant differences in different BMI groups (p<0.01) and that the mean of these vertebrae (in terms of height, width and length) were higher and wider in people with higher BMI than in people with lower and medium BMI (Table 4).

Table 4: Determining the relationship between height and morphological status in the study population.

Discussion

In this study, we examined the morphological status of the cervical spine (C3-C7) in patients referred to Taleghani Hospital in Kermanshah with a sample size of 450 patients. The results of this study showed that the mean of these vertebrae (in terms of height, width and length) were higher and wider in men than in women, which is consistent with the results of the studies by Ezra et al. that aimed to "investigate the demographic aspects of the size and shape of the cervical vertebrae body (C3-C7)" that were conducted in 2017 and 2019 and showed that the shape and size of the cervical vertebrae body had a significant statistical relationship with gender, such that the size of the vertebrae body in men was significantly larger than in women. The results of this study are also in line with the study by Been, Shefi and Soudack that aimed to determine the role of gender in creating cervical spine lordosis, based on the need of considering the patient's gender by physicians before performing neck stabilization or repair procedures. Another study that is consistent with our study is the study by Rozendaal et al. entitled "Estimating the effect of gender on the morphology of the seven cervical vertebrae: analysis of two European populations" that showed that the variables of maximum vertebrae body height (CHT) and transverse foramen diameter (CTR) had a significant statistical relationship with the patients' gender [7].

Another study that is consistent with our research is the study by Fahimeh Keyvanloo, Mohammad Seyed Ahmadi and Akbar Pejhan entitled "Radiographic components of forward head posture and its relationship with gender and height". In this descriptive-analytical study, 300 students from Razi University of Kermanshah were randomly selected from both boys and girls and evaluated and screened using the Posture Pro V (PPV) software. Those who had the most severe Forward Head Posture (FHP) (5s. 11.31) and lower cervical lordosis (23.11 vs. 33.77) than tall people and men (P<0.01). They also found that the forward head posture caused a reduction in the natural lordosis of the neck and the emergence of kyphosis of the neck and in case of severe forward head posture, an S-shaped curve that resulted from the decrease in the lower curve of the cervical vertebrae (C2-C7) and the increase in the upper curve of the cervical vertebrae (C1-C2) might be formed. According to the final result of this research, forward head posture causes a reduction in the natural lordosis of the neck and the creation of kyphosis of the neck and increasing height does not cause an increase in the forward head posture but women have more severe forward head posture than men [8]. Which is in agreement with our research in terms of the effect of gender on the morphological status of the cervical spine.

Another study that is in line with our research is the study by Farzaneh Moslemi Haghighi, Mohammad Reza Fotouhi Abadi and Ali Ghanbari entitled "Investigating the prevalence of head forward position and its relationship with various variables in high school students of Shiraz city". In this descriptive-sectional study, 240 female and 240 male high school students of Shiraz city were randomly selected by systematic cluster sampling and the relationship between head forward position and variables such as gender, study position, visual impairment and exercise was examined. First, the necessary information from each sample was recorded in the questionnaire and then the head forward position of the samples was checked and recorded by the plumb line. The results of the study showed that the prevalence of head forward position from the left and right sides was 76.1% and 74.6%, respectively, and there was a significant difference between head forward position and gender, study position and exercise (p<0.05), but no significant difference was seen for visual impairment. In this study, the relationship between gender and the morphological status of the cervical spine was confirmed, which is consistent with our study.

Another study that was conducted by Hasan Daneshmandi, Hossein Pour Hosseini and Mohammad Ali Sardar entitled "Comparative study of spinal abnormalities in male and female students" involved 616 middle school students as the research sample, including 300 girls and 316 boys with an age range of 15-12 who voluntarily participated in the study and the sampling method was random and cluster. The most important results of this research are that 79.75 percent of boys and 81.66 percent of girls and in general 80.68 percent of the research population have spinal posture abnormalities. The results of the study showed that there was a significant difference between the spinal status of boys and girls (P<0.01) and in general, in the assessment of the spinal status of the subjects, it was observed that the prevalence rate of most abnormalities in girls was higher than boys. Which is in agreement with the result of our research.

The results of this study showed that the average of these vertebrae (in terms of height, width and length) were higher and wider in ages above 60 years than lower ages, which is consistent with the results of the study by Ezra et al. that was conducted in 2017 and 2019 that showed that with the increase of the patients' age, the shape changes of the cervical vertebrae became more elongated, wider and shorter. The results obtained with the aim of determining the relationship between age and morphological status in the current study population showed that the vertebrae C3 and C5 in superior vertebral body wider, the vertebrae C3 and C4 in superior vertebral body length, the vertebra C4 in inferior vertebral body wider, the vertebrae C4 and C5 in posterior vertebral body high, the vertebra C6 in superior vertebral foramina wider and the vertebra C3 in superior vertebral foramina length had significant differences in different ages; meaning that the average of these vertebrae (in terms of height, width and length) were higher and wider in ages above 60 years than lower ages.

Ezra et al. in 2019 in a study entitled "Investigating osteophytes in the cervical vertebrae body (C3-C7) from the perspective of demographic characteristics" based on the findings of CT-scan of the cervical spine (C3-C7) of 273 patients examined them in terms of age. The findings obtained from this study showed that the prevalence of osteophytes was only related to age in the upper cervical vertebrae (C3-C4), which is also the result of our research. In another study with the aim of determining the anatomical characteristics of the cervical spine based on age, which was done by Parenteau et al. in 2015; the researchers examined the findings of CT-scan of 750 patients, 314 of whom were children and 436 of them were adults, in line with their research objectives. The findings from this study showed that the height of the vertebrae body had a positive non-linear and statistically significant relationship with the patients' age, which is also a result that supports the results obtained from our research [9].

Another study that was done by Ali Asghar Nourasteh and Hamid Zolqadr with the aim of "investigating the effect of age on the alignment and range of motion of the cervical spine" from 1999 to 2020, this study was a comprehensive review of the effect of age on the alignment and range of motion of the cervical spine through searching in Google Scholar, PubMed and Scincedirect databases with keywords cervical spine, neck, range of motion, cervical alignment, cervical angle and age-related change and also Persian databases Google Scholar, Magapaper, Irandoc, Magiran, Scientific Information Center of Jihad University, Medlib, Iran Medex and Iran Science and Technology Institute with keywords neck, cervical spine, range of motion, cervical alignment, cervical angle and age-related change and after reading the abstracts of the articles and matching them with the study criteria, we finally chose 37 articles for the study. These studies mainly studied the effect of age on the range of motion and cervical alignment in healthy individuals. According to the results of the studies, with the increase of age, the range of motion in the cervical spine decreases, which does not follow a regular pattern, because it increases in some ages and decreases in some ages. The result of the study also showed that the increase of age not only affects the range of motion but also affects the cervical spine alignment [10].

The results showed that the average of these vertebrae (in terms of height, width and length) were higher and wider in heights above 180 meters than shorter heights. In the study of the relationship between height and morphological status, the results showed that the vertebrae C5 and C6 in superior vertebral body wider, the vertebrae C3 and C4 in inferior vertebral body length and the vertebra C5 in posterior vertebral body high had significant differences in different heights; meaning that the average of these vertebrae (in terms of height, width and length) were higher and wider in heights above 180 meters than shorter heights. In a study entitled "Investigating the changes of cervical lordosis and cervico-vertebral morphology in different ages" that was done in 2015; LaziÄ? et al. examined 120 patients in 3 age groups of 8, 13-12 and 18-17 years in line with their research objectives. The researchers concluded that there was a significant statistical relationship between the angle of cervical lordosis and the anterior and posterior height of the vertebrae body (AVBH and PVBH) of the vertebrae C3, C4 and C5, the anterior intervertebral space of C4- C5 and the posterior of C2-C3, C3-C4 and C4-C5.

Another study that was done by Gholamhossein Saljooghi and Behnam Mirzaei with the aim of "investigating the recognition of abnormalities in 11 to 13 year old male students and their relationship to three factors of age, weight and height" was conducted on 1688, 11 to 13 year old male students of Karaj city with an average height of 152 ± 0.68 meters and an average weight of 2.49 ± 7.48 kilograms. In this study, first, using a digital camera, each of the subjects was photographed from three views (anterior-posterior-lateral) and then, using the corrective movements software, the abnormalities of these students were evaluated and recorded. The findings showed that: There was a significant relationship between the age factor and the abnormalities of head forward, kyphosis, scoliosis and pelvic drop and there was a significant relationship between the height factor and the abnormalities of head forward, kyphosis, scoliosis, knee valgus and pelvic drop. Therefore, it can be concluded that the occurrence of these abnormalities is related to factors such as age and height.

Conclusion

Both conclusions are consistent with the results of our research. The results of this study indicated that the average of these vertebrae (in terms of height, width and length) were higher and wider in people with higher BMI than people with medium and low BMI. In the study of the relationship between BMI and morphological status of the cervical spine, the results showed that the vertebrae C3, C4 and C5 in superior vertebral body wider, the vertebra C3 in superior vertebral body length, the vertebra C3 in inferior vertebral body wider, the vertebra C7 in inferior vertebral body length, the vertebra C6 in anterior vertebral body high and the vertebra C6 and C7 in posterior vertebral body high had significant differences in different BMI; meaning that the average of these vertebrae (in terms of height, width and length) were higher and wider in people with higher BMI than people with medium and low BMI. These results were consistent with the results of the study by Mohammad Rahimi, Faezeh Shah Mohammadi and Amaneh Ghasemi that was entitled "Investigating the prevalence of musculoskeletal disorders in workers of Yutab factory and its relationship with posture during work, work history and body mass index" that was done on 60 workers of Yutab factory based on the entry and exit criteria. Musculoskeletal disorders were evaluated and analyzed by using the Nordic questionnaire and work history by questionnaire and posture during work by REBA test. Body mass index of workers was also obtained by using a scale and a height meter and using the formula (weight (kg)/height (m)2). Spearman correlation test showed a significant relationship between all variables of posture during work, work history and body mass index with the most common musculoskeletal disorders.

According to the results obtained in this study and comparing them with the results obtained in the researches with the same objectives as our study, it was determined that in terms of morphology (length, width and height) of the cervical spine (C3- C7) in men, people over 60 years old, height more than 180 centimeters and high BMI; they were higher and wider.

References

1. Brown AA, Aidoo E, Gyimah ES, Kyei G (2023) The anatomy of the uncinate process of C3-C7 cervical vertebrae in the Ghanaian population. J Morphol Sci 40:290

   [Crossref]

2. Lin S, Bao M, Wang Z, Zou X, Ge S, et al. (2021) Morphological evaluation of the subaxial cervical spine in patients with basilar invagination: A CT-based study. Spine 46:1387-1393

   [Crossref] [Google Scholar] [PubMed]

3. Panjabi MM, Shin EK, Chen NC, Wang JL (2000) Internal morphology of human cervical pedicles. Spine 25:1197-1205

   [Crossref] [Google Scholar] [PubMed]

4. Zhang S, Wang X, Ren X, Li Z, Zhang Y (2017) Applications of digital technology for the morphological study of C3–C7 vertebral arch pedicle in children. Folia Morphol 76:426-432

   [Crossref] [Google Scholar] [PubMed]

5. Ahmed SH, El-Shaarawy EA, Ishaq MF, Moniem MA (2014) Morphological and radiometrical study of the human intervertebral foramina of the cervical spine. Folia Morphol 73:7-18

   [Crossref] [Google Scholar] [PubMed]

6. Prabavathy G, Philip XC, Arthi G, Sadeesh T (2017) Morphometric study of cervical vertebrae C3-C7 in South Indian population–a clinico-anatomical approach. Ital J Anat Embryol 11:49-57

   [Google Scholar]

7. Bazaldua CJ, Gonzalez LA, Gomez SA, Villarreal SE, Velazquez GS, et al. (2011) Morphometric study of cervical vertebrae C3-C7 in a population from northeastern Mexico. Int J Morphol 29:325-330

   [Google Scholar]

8. Westermann L, Spemes C, Eysel P, Simons M, Scheyerer MJ, et al. (2018) Computed tomography-based morphometric analysis of the cervical spine pedicles C3–C7. Acta Neurochir 160:863-871

   [Crossref] [Google Scholar] [PubMed]

9. Rahman WU, Jiang W, Zhao F, Li Z, Wang G, et al. (2023) Biomechanical effect of C5-C6 intervertebral disc degeneration on the human lower cervical spine (C3-C7): A finite element study. Comput Methods Biomech Biomed Engin 26:820-834

   [Crossref] [Google Scholar] [PubMed]

10. Kim JY, Kwon JY, Kim MS, Lee JJ, Kim IS, et al. (2018) Comparison of morphological characteristics of the subaxial cervical spine between athetoid cerebral palsy and normal control. J Korean Neurosurg Soc 61:243-250

    [Crossref] [Google Scholar] [PubMed]