CT Morphometric Analysis to Determine the Anatomical

Basis for the Use of Transpedicular Screws during

Reconstruction and Fixations of Anterior Cervical
Vertebrae
Chun Chen1,2,3, Dike Ruan2, Changfu Wu1, Weidong Wu1, Peidong Sun1, Yuanzhi Zhang4, Jigong Wu5,
Sheng Lu6, Jun Ouyang1,7*
1 Department of Anatomy, Southern Medical University and Guangdong Provincial Medical Biomechanical Key Laboratory and Academy of Orthopedics of Guangdong
Province, Guangzhou, Guangdong, China, 2 Department of Orthopedic Surgery, The Navy General Hospital, Southern Medical University, Beijing, China, 3 The Third School
of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China, 4 Department of Orthopedic Surgery, Affiliated Hospital of Inner Mongolia Medical
College, Inner Mongolia, China, 5 Department of Orthopedic Surgery, The 306th Hospital of People’s Liberation Army, Beijing, China, 6 Department of Orthopedic Surgery,
Kunming General Hospital, Kunming, Yunnan, China, 7 Shenzhen Digital Orthopedic Engineering Laboratory, Shenzhen, Guangdong, China

Abstract
Background: Accurate placement of pedicle screw during Anterior Transpedicular Screw fixation (ATPS) in cervical spine
depends on accurate anatomical knowledge of the vertebrae. However, little is known of the morphometric characteristics
of cervical vertebrae in Chinese population.

Methods: Three-dimensional reconstructions of CT images were performed for 80 cases. The anatomic data and screw
fixation parameters for ATPS fixation were measured using the Mimics software.

Findings: The overall mean OPW, OPH and PAL ranged from 5.81 to 7.49 mm, 7.77 to 8.69 mm, and 33.40 to 31.13 mm
separately, and SPA was 93.54 to 109.36 degrees from C3 to C6, 104.99 degrees at C7, whereas, 49.00 to 32.26 degrees from
C4 to C7, 46.79 degrees at C3 (TPA). Dl/rSIP had an increasing trend away from upper endplate with mean value from 1.87 to
5.83 mm. Dl/rTIP was located at the lateral portion of the anterior cortex of vertebrae for C3 to C5 and ipsilateral for C6 to C7
with mean value from 22.70 to 23.00 mm, and 0.17 to 3.18 mm. The entrance points for pedicular screw insertion for C3 to
C5 and C6 to C7 were recommended 22,23 mm and 0–4 mm from the median sagittal plane, respectively, 1–4 mm and
5–6 mm from the upper endplate, with TPA being 46.79–49.00 degrees and 40.89–32.26 degrees, respectively, and SPA
being 93.54–106.69 degrees and 109.36–104.99 degrees, respectively. The pedicle screw insertion diameter was
recommended 3.5 mm (C3 and C4), 4.0 mm (C5 to C7), and the pedicle axial length was 21–24 mm for C3 to C7 for
both genders. However, the ATPS insertion in C3 should be individualized given its relatively small anatomical dimensions.

Conclusions: The data provided a morphometric basis for the ATPS fixation technique in lower cervical fixation. It will help
in preoperative planning and execution of this surgery.

Citation: Chen C, Ruan D, Wu C, Wu W, Sun P, et al. (2013) CT Morphometric Analysis to Determine the Anatomical Basis for the Use of Transpedicular Screws
during Reconstruction and Fixations of Anterior Cervical Vertebrae. PLoS ONE 8(12): e81159. doi:10.1371/journal.pone.0081159
Editor: Jeroen Hendrikse, University Medical Center (UMC) Utrecht, The Netherlands
Received July 6, 2013; Accepted October 18, 2013; Published December 11, 2013
Copyright: ß 2013 Chen et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by National Natural Science Foundation of China grant No. 31170903. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: jouyang@126.com

Introduction region are relatively higher [8–10]. In many cases both anterior
and posterior approaches are employed and can be named
Cervical spine injury, instability, degenerative diseases, circumferential surgery as in global fusion for tumor radical
cancer, osteoporosis and other pathological diseases affecting excisions [4]. Improved implant design, metallurgy and biome-
anterior vertebral bodies are commonly encountered by spinal chanical analysis of failures, have led to development of newer
surgeons [1]. Anterior cervical inter-body fusion (ACIF), fixation devices and surgical techniques especially for cases
posterior cervical pedicle screw (pCPS) and lateral mass screw involving multiple segment fixation and patients with osteopo-
(LMS) are the most commonly performed surgical interventions rosis [11]. Circumferential revision involving global fusion
and have consistently acceptable results [2–7]. Despite accept- surgery can effectively solve the problem and improve stability,
able results with the use of both techniques, the number of but a second surgery increases the patient’s morbidity and adds
complications and failures when compared to surgeries in other to the cost of treatment significantly.

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 Cervical Anterior Transpedicular Screw Fixation

It is necessary that we devise unique methods of fixation that length, width and depth were measured on the cutting plane, and
have all the advantages of circumferential surgery without of the sagittal or coronal sections views were rotated to ensure that the
disadvantages of increased morbidity and cost. Koller et al [12] computation of axial line of pedicle was located at the central
described anterior cervical transpedicular screw (ATPS) fixation to cervical pedicle by visual observation. After vertebrae cutting, the
solve the above problems in 2008 and reported his results from a specific parameters [12] used during the measuring process are
study on morphological feasibility, indications, and technical illustrated in Table 1 and Fig. 1. The detailed following
prerequisites for the same. Many studies have shown that there are parameters were assessed: aVBH (anterior Vertebral Body
a great degree of morphological differences between the Asian and Height), mVBD (midbody Vertebral Body Depth), mVBW
European/American populations [13], especially in the femur (midbody Vertebral Body Width), l/rOPW (left/right Outer
[14–16] and cervical vertebrae regions [13,17,18]. In order to Pedicle Width), l/rOPH (left/right Outer Pedicle Height),l/rTPA
achieve optimal surgical outcomes, it is therefore imperative that (left/right Transverse Pedicle Angle), l/rSPA (left/right Sagittal
pertinent anatomical data, especially with regard to pedicles and Pedicle Angle), l/rPAL (left/right Pedicle Axis Length), l/rTIP
vertebral bodies, be obtained. This study was done to measure (left/right Transverse Intersection Point), Dl/rTIP (Distance left/
morphometric parameters of different cervical vertebrae in the right Transverse Intersection Point), l/rSIP (left/right Sagittal
Chinese population using Mimics image processing software. Intersection Point), Dl/rSIP (Distance left/right Sagittal Intersec-
tion Point).
Materials and Methods One researcher measured all the data by Mimics workstation.
Linear and angular measurements were done from C3 to C7. All
Ethics statement parameters were measured three times by the first author (C.C),
The study protocol was ethically approved by the Human and the mean was used as the final value [2,17].
Research Ethics Committee of Kunming Military General Considering a three-dimensional screw entrance point, it can be
Hospital (Yunnan) and Human Research Ethics Committee of observed that in sagittal plane, the lSIP and rSIP, and in transverse
the 306th Hospital of People’s Liberation Army (Beijing) and plane, lTIP and rTIP, respectively, resemble conceivable entry
Human Research Ethics Committee of Affiliated Hospital of Inner points for ATPS into the left and right pedicles. The entry points
Mongolia Medical College (Inner Mongolia). Prior written resemble the projection of the center of a corridor formed by the
informed consent was obtained from all study participants. cervical pedicles onto the anterior vertebral cortex, both in the
coronal and sagittal plane. Concurrently with the l/rSIP, mean
Sample collection and measurement method data of l/rTIP at the levels C3 to C7 were visualized to assess their
The study consisted of 80 patients (35 females and 45 males), importance during insertion of ATPS for all levels except C2
who underwent cervical CT examination in Kunming Military [12,19]. The distances between sagittal intersection points were
General Hospital, the 306th Hospital of People’s Liberation Army measured along the anterior cervical column and could be angled
and Affiliated Hospital of Inner Mongolia Medical College during and interrupted at the superior and inferior corner of each
a period lasting from June 1, 2011, to July 30, 2012. The mean age vertebral body using a polygon measuring tool. Regarding
for all patients was 52.51 years (range 25–76 years), the mean age measurements of l/rTIP, those pedicle axes which crossed the
of patients was 49.14 years for males and 53.3 years for females. mid-sagittal line were scaled as ‘positive’ values, and those
None of the patients had any evidence of infectious, neoplastic, intersecting the anterior vertebral body lateral to the mid-sagittal
traumatic, or degenerative diseases involving the spine, or any line were scaled as ‘negative’ values. The method of measurement
evidence of congenital or developmental spinal malformation. All was adapted from the technique reported by Koller [3,12,19,20].
patients were scanned using a helical CT scanner (Somatom
Sensation 64, Siemens Medical Solutions, Erlangen, Germany). Data collection and statistical analysis
Because proper slice thickness is important for the performance of The ranges, means and standard deviations (Mean6SD) for
high quality multi-planar reformation, a skilled technician and each parameter were calculated. To compare between the right
appropriate imaging apparatus were used. The primary DICOM and left pedicles, all paired structures of the vertebrae were
images were acquired using a standard algorithm with 1.25 mm measured individually and an independent samples t-test was
slice thicknesses and 0.6 mm reconstruction intervals. Reconstruc- performed with the significance set at 95% confidence level. Post-
tions were performed using Mimics 14.11 (Materialise Corp., hoc comparisons were done to compare factor levels. Statistical
Leuven, Belgium). Before measurements were made and the data analyses were performed using SPSS 19.0 software (SPSS,
collected, the calibrated phantom model had to be established. As Chicago, Illinois, USA).
shown in Fig. 1,2 3, the DICOM images from the regions of
interest are converted to 3-D surface models using an adapted Results
marching cubes algorithm that takes the partial volume effect into
account, leading to highly accurate 3-D models on which The CT data pool comprised 400 cervical vertebrae. All
measurements can be performed. An interactive image processing parameters were measured and described in Tables 2, 3, 4.
strategy (‘‘Threshold’’ and ‘‘Region growth’’) was used to segment Thirteen linear and four angular parameters wcere measured in
the contours of each vertebra. In this study, a lower threshold of cervical vertebrae. The resultant P,0.05 showed that all linear
226 Hounsfield units and an upper threshold of 3071 Hounsfield and angular measurements were significant statistically in any
units were used. The 3-D reconstruction of each vertebra can be parameter.
freely translated and rotated. The vertebral anatomic structure
(such as, left and right anterior or posterior part of unicinate Linear measurements
process, left and right medial edge of transverse foramen, and There were statistically significant interlevel differences in
anterior or posterior mid-sagittal line of vertebral) had to be mVBD between male and female patients (P,0.05). However,
defined. For pedicle measurement, a degree of cutting accuracy statistically differences were found between C5 and C6, C6 and
will depend on fitting the center line of the pedicle of a 3-D model C7 for both gender in mVBW, aVBH (P,0.05). There was a
which was determined by pedicle curvature. The vertebral pedicle tendency to increase from C3 to C7 for mVBW (Table 2).

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 Cervical Anterior Transpedicular Screw Fixation

Figure 1. Morphological parameters in Mimics software relating to Table 1.

doi:10.1371/journal.pone.0081159.g001

There were significant differences between left and right sides of Statistically significant differences (P,0.05) were found between
C7 in males and females concerning PAL (P,0.05). Measure- males and females in all levels except for C7. No significant
ments of PAL showed interlevel statistically significant differences differences in males were observed between OPW of C3 and
between the level C7 and C3 to C6 (P,0.05) irrespective of C4, C4 and C5 except for other interlevel comparison (P,0.05).
genders or sides. No statistically significant differences were found In females, statistically significant differences (P,0.05) were
for PAL between males and females. There was a similar length of identified in all of the interlevel except for between C3 and C4.
PAL from C3 to C6 except for C7. The lowest value in our Taken together, the mean left and right OPW of the entire
measurement was no less than 25 mm in males or females group, no statistically significant differences were only found
(Table 3). between C3 and C4. The frequency of OPW below 5 mm was
No significant left or right differences in OPW were found for 18.89% at C3, 13.82% at C4, 4.34% at C5, 2.56% at C6 and
any of the patients (Table 3). However, merging left and right 0% at C7, as well as the frequency of OPW below 4 mm was
OPW data, gender as well as vertebral level showed to be a 0% (Table 3).
statistically significant factor (P,0.000, P,0.000). The OPW Concerning OPH of all patients, there were no significant
showed a tendency to increase from C3 to C7 (5.81–7.49 mm). differences between left and right sides, however gender and

Figure 2. The process of part of measuring parameters using Mimics 14.11 software. A: The target vertebra was chosen in Mimics 14.11
software. Three lines (AP-UP, ME-TE, PP-UP) were drawn and the cutting plane was adopted with the midpoint of the three lines. 1, AP-UP: The line
between left and right anterior part of unicinate process. 2, ME-TF: The line between left and right medial edge of transverse foramen. 3, PP-UP: The
line between left and right posterior part of unicinate process. B: Profile of the cutting plane can be observed by rotation. C: The cutting vertebral
body was colored. D: The aVBH was measured.
doi:10.1371/journal.pone.0081159.g002

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 Cervical Anterior Transpedicular Screw Fixation

Figure 3. The process of OPH measurement. E: The red fitting axial line of pedicle was computed by pedicle curvature using Mimics software
and can be observed by transparency. F: Profile of the cutting plane and can be observed by rotation. G: The cutting pedicle was colored. H: The OPH
was measured.
doi:10.1371/journal.pone.0081159.g003

vertebral level proved to be a statistically significant factor differences (P,0.05) were observed between C3 and C7, C5 and
(P,0.000, P,0.000). Statistically significant differences (P,0.05) C7. Merging males and females, a statistically significant interlevel
were found between males and females in all levels. Statistical difference (p,0.05) existed between C3 and C4 to C7 (Table 3).
analysis revealed significant differences (P,0.05) in males between The diameters of all ranges were no less than 5.5 mm in all
OPH of C3 and C5 to C6, C6 and C7. In females, significant patients (Table 3).

Table 1. Cervical anterior transpedicular screw fixation anatomical parameters.

Parameter Measurement Description

aVBH Anterior Vertebral Body Height Distance cephalad to caudad endplate at mid-sagittal line
mVBD Midbody Vertebral Body Depth Antero-posterior vertebral body depth at mid-sagittal line
mVBW Midbody Vertebral Body Width Transverse distance from left to right border of vertebral body at mid-vertebral line
l/rOPW Left/right Outer Pedicle Width Distance from medial border of transverse foramen to medial border of pedicle
l/rOPH Left/Right Outer Pedicle Height Distance from upper to lower pedicle surface in sagittal plane
l/rTPA Left/Right Transverse Pedicle Angle Angle formed between transverse pedicle axis and mid-sagittal line
l/rSPA Left/Right Sagittal Pedicle Angle Angle formed between plane of anterior vertebral body wall at mid-sagittal line and sagittal
pedicle axis
l/rPAL Left/Right Pedicle Axis length Distance from anterior vertebral body wall to posterior margin of lateral mass along the
transverse pedicle axis
l/rTIP Left/Right transverse Intersection Point Transverse intersection point of transverse pedicle axis with anterior vertebral body wall
Dl/rTIP Distance left/right transverse Intersection Distance between transverse intersection point and mid-sagittal line at the anterior vertebral
Point body wall at each cervical level C3–C7
l/rSIP Left/Right sagittal Intersection Point Sagittal intersection point of sagittal pedicle axis with anterior vertebral body wall
Dl/rSIP Distance left/right sagittal Intersection Distance between sagittal intersection points and cephalad endplate at each cervical level C3 to
Point C7.

Reproduced with permission from Koller [12].

doi:10.1371/journal.pone.0081159.t001

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 Cervical Anterior Transpedicular Screw Fixation

Table 2. Linear parameters measured of the aVBH, mVBD and mVBW (Mean6 SD, mm).

Cervical level aVBH mVBD mVBW

Male Range Female Range All Range Male Range Female Range All Range Male Range Female Range All Range

C3 14.1661.61 13.4560.99 13.9461.47 17.4161.90 15.0461.20 16.6762.03 20.6361.83 19.5761.93 20.3061.91

9.41–16.27 11.67–15.27 9.41–16.27 12.65–21.43 12.65–16.71 12.65–21.43 15.67–24.63 16.76–23.32 15.67–24.63
C4 14.0061.62 12.9060.71 13.6761.49 17.4761.90 14.8561.35 16.6962.12 21.4562.03 20.2561.70 21.0962.00
8.44–16.21 11.56–14.06 8.44–16.21 12.20–21.93 11.24–16.85 11.24–21.93 16.15–25.38 17.87–23.19 16.15–25.38
C5 13.1361.59 12.0461.07 12.8061.52 17.0761.69 15.1662.12 16.5062.01 22.5162.31 21.0962.21 22.0862.35
9.53–15.35 10.48–14.57 9.53–15.35 12.48–21.04 11.35–20.55 11.35–21.04 17.04–27.88 16.95–25.19 16.95–27.88
C6 13.2261.67 12.2160.96 12.9461.56 17.3661.79 15.1661.99 16.7462.08 24.3762.11 23.7862.11 24.2062.10
8.27–16.78 10.46–14.22 8.27–16.78 13.49–21.81 11.69–18.56 11.69–21.81 20.70–29.07 21.28–27.62 20.70–29.07
C7 14.6161.59 13.7361.05 14.3561.49 17.0061.57 15.1761.91 16.4561.86 27.7162.44 26.3062.06 27.2962.40
10.22–17.01 12.37–15.36 10.22–17.01 13.68–20.69 11.37–17.95 11.37–20.69 21.19–32.78 23.66–29.18 21.19–32.78

doi:10.1371/journal.pone.0081159.t002

Table 3. Linear parameters for pedicle characterization (Mean6SD, mm).

Cervical level OPW OPH PAL

left Range right Range left Range right Range left Range right Range

C3 Male 6.0260.74 6.1460.84 8.0960.94 7.9260.99 34.3961.70 34.1961.95

4.68–7.60 4.59–8.42 5.81–9.71 5.95–10.96 30.25–37.56 28.45–38.01
Female 5.3460.60 5.0960.77 7.2660.70 7.2960.74 31.2661.70 31.6161.14
4.55–6.46 4.38–7.09 6.41–8.55 5.85–8.36 29.09–34.33 30.04–33.41
All 5.8160.85 7.7760.94 33.4062.15
C4 Male 6.0860.69 6.1960.82 8.8561.12 8.7361.01 34.8362.24 34.6562.08
4.41–7.70 4.50–8.05 6.60–11.20 5.80–10.85 29.20–38.90 29.61–38.35
Female 5.3560.58 5.1660.60 7.8760.73& 7.5160.71 31.9762.28 32.3562.47
4.22–6.10 4.32–6.19 6.66–8.90 6.26–8.70 28.28–35.74 28.43–35.86
All 5.8760.81 8.4661.09 33.9762.49
C5 Male 6.4360.88 6.6060.83 8.5561.25 8.5761.20 35.4363.19 35.8762.90
4.83–8.29 4.62–8.29 5.90–10.84 5.67–11.20 27.00–42.64 30.65–43.60
Female 5.8660.80 5.8660.73 7.4960.69 7.2760.46 32.4662.12 33.5663.04
4.83–7.87 4.54–7.33 6.26–8.92 6.57–8.39 29.06–35.86 28.44–39.73
All 6.3160.87 8.2061.19 34.8463.14
C6 Male 6.9160.761 6.9960.71 8.4561.11 8.3561.32 34.4063.47 34.6362.96
5.44–8.77 5.86–8.67 6.65–11.06 5.98–11.09 25.64–40.62 28.96–40.54
Female 6.1860.86 6.1960.86 7.5860.89 7.6860.71 31.7762.78 32.6262.67#
4.93–8.21 4.97–7.65 6.64–9.06 7.01–8.98 28.44–35.32 29.03–36.33
All 6.7360.83 8.1861.15 33.8563.21
‘ ‘
C7 Male 7.5560.90 7.6760.89 8.9361.15 8.9761.32 30.5662.50 32.3662.16
5.91–8.94 5.58–9.86 6.27–11.34 5.85–12.44 25.62–34.09 27.71–35.66
Female 6.1960.86D 7.1460.50D 8.1260.97 8.0460.74 29.4962.48D& 31.0261.98D&
6.04–8.60 6.40–8.09 6.68–9.32 7.01–9.05 25.37–32.54 27.59–34.22
All 7.4960.85 8.6961.19 31.1362.50

#
Compared with rPAL between males and females in C6; P.0.05,
D
Compared with l/rOPW and l/rPAL between males and females in C7, P.0.05,
‘
Statistically significant differences in males of l/rPAL (C7); P,0.05,
&
Statistically significant differences in females of l/rPAL (C7) P,0.05.
doi:10.1371/journal.pone.0081159.t003

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 Cervical Anterior Transpedicular Screw Fixation

Table 4. Linear parameters and angular measurements for vertebral characterization (Mean6SD).

Cerv
ical
level TPA(degrees) SPA(degrees) DTIP(mm) DSIP(mm)

left Range right Range left Range right Range left Range right Range left Range right Range

C3 Male 48.5664.35‘ 46.1663.65‘ 93.3367.84 92.2967.29 23.7162.28 23.0461.93 2.1861.28 1.7660.80

38.46–60.99 41.06–55.64 7 3.65–112.29 76.29–106.0 28.83–2.33 28.56–2.55 0.20–5.67 0.10–3.28
Female 46.7863.40* 44.2863.88* 93.3963.16* 93.9263.64* 21.8360.98* 21.5661.77* 1.7060.69* 1.6460.71*
4.26–51.95 39.33–53.80 86.17–113.31 87.73–99.12 23.32–0.00 24.92–1.10 0.71–2.77 0.10–2.65
All 46.7964.11 93.54.9766.91 22.7062.50 1.8760.98
C4 Male 51.0865.17‘ 47.7965.33‘ 99.2269 .18 98.5869.49 24.4562.57 23.8362.80 2.6561.36 2.9061.42
38.93–69.14 31.39–56.05 83.06–126.85 76.71–116.47 210.84–2.42 27.77–3.96 0.22–6.43 0.00–6.71
Female 49.2565.6 46.7265.58 100.3667.30 97.8567.26 23.0062.69 22.5362.85 2.8061.11 2.3960.89
39.98–61.47 38.63–57.11 88.59–110.03 84.14–105.26 26.47–2.73 28.66–2.18 0.96–4.46 0.57–3.83
All 49.0065.53 98.9568.68 23.7362.75 2.7261.28
C5 Male 48.5866.43 47.5667.72 105.5167.74 108.5968.40 23.7063.54 23.2262.64 4.00 61.41‘ 4.4861.66‘
34.16–60.04 35.38–80.19 86.41–117.04 89.73–130.32 210.85–5.55 26.83–3.01 1.48–7.72 2.08–8.69
Female 47.0464.65 45.7065.08 105.16611.25 106.61610.14 22.0762.57 22.2562.96 3.3761.34 3.7761.88
38.32–53.48 34.03–52.85 86.09–129.69 85.52–124.37 26.47–2.99 27.07–3.82 1.56–5.64 1.47–8.51
All 47.5566.48 106.6968.90 23.0063.03 4.0361.59
C6 Male 41.3768.32 40.5466.35 108.6368.69 109.1567.53 0.1364.49 0.0263.49 5.7962.46 5.6462.03
29.86–58.75 25.48–56.57 96.86–133.63 96.21–126.24 26.10–7.68 24.91–8.56 2.35–11.82 2.67–10.88
Female 40.2765.81 41.2565.61 110.4566.57 110.6668.57 1.1062.46 20.2262.91 5.3561.28 5.4661.27
32.08–49.59 30.12–51.91 100.28–118.64 99.19–129.63 22.93–3.90 26.61–4.50 3.81–8.13 3.79–8.04
All 40.8966.86 109.3667.88 0.1763.65 5.6261.99
C7 Male 32.7164.41 31.9262.69 104.9868.32 104.0267.38 3.5962.12 2.7761.75 5.7861.14 5.8261.45
25.96–41.22 26.80–36.15 92.99–130.57 91.61–118.25 0.00–8.81 0.00–6.59 3.98–7.93 2.88–8.88
Female 30.8864.26& 33.3963.16& 108.2066.74 104.1164.05 4.0161.95 2.4161.25 5.8261.45& 5.9861.26
23.99–39.14 26.44–38.26 93.74–115.00 99.07–112.89 1.20–7.53 0.92–5.58 3.49–8.90 4.60–8.68
All 32.2663.68 104.9967.26 3.1861.90 5.8361.29

*Compared with l/rTPA, l/rSPA, l/rDSIP, l/rDTIP between males and females in C3, P,0.05;
‘
Statistically significant differences in males of l/rTPA (C3, C4), and l/rDSIP (C5), P,0.05,
&
Statistically significant differences in females of l/rTPA(C7) and l/rDSIP (C7) P,0.05.

Angular measurements increasing trend away from upper endplate (1.87–5.83 mm) and
With the TPA and SPA (C3–C7), there were no significant Dl/rTIP had a trend of contralateral turning ipsilateral in C3 to
gender- or side-related differences except at C3 level (P,0.05). C7 (22.70,3.18 mm, Tables 4). There were no significant
Merging males and females, there was a tendency for an increase male versus female, or left versus right differences detected.
of TPA from C3 to C4 (46.79–49.00 degrees) with a reversal of Merging all the data, no statistically differences of Dl/rTIP
that increase from C5 to C7 (47.55–32.26 degrees), as well as SPA was found between C3 and C4 to C5, and between C4 and
from cephalad C3 to caudad C6 (93.54–109.36 degrees) which C5 (Table 4). Using anatomical trajectories of pedicle axis
subsequently slightly decreased from C6 to C7 (109.36–104.99 for measuring the l/rSIP, the frequency of these l/rSIP with
degrees). No statistically significant interlevel differences of TPA a distance below 3 mm to its adjacent cephalad disc spaces
calculated from merged data of all 80 patients. Significant was 92.22% at C3, 63.82% at C4, 27.17% at C5, 6.41% at
differences (P,0.05) were observed between TPA of C6 or C7 C6, and 1.35% at C7. Clinically there is a wider corridor in
and C3 to C5, then, SPA of C3 and C6 to C7 for both genders, the sagittal plane to place a 3.5 mm screw inside the
respectively (Table 4). pedicles and sufficiently beneath adjacent disc spaces but this
is significantly diminished at the level of C3. The pedicle
Intersection points axes intersect each other in the anterior part of the vertebral
DTIP and DSIP determine the space in the anterior vertebral body in C3 to C5. The mean distances measured between
body for pedicle screws. In measuring distances between lTIP or the midsagittal line and l/rTIP shifts slightly from the
rTIP and the mid-sagittal line (Dl/rTIP) at the maximum was at contralateral to the midsagittal line of the pedicle axis in C3
C7 in males (8.81 mm) and the minimum was at C5 in males to C5 and towards the ipsilateral side in C6 to C7. Mostly,
(210.85 mm, Table 4). Mean distances from adjacent cephalad pedicle axes that did not cross the midsagittal line at the
endplates and mid-sagittal line to the sagittal and transverse anterior vertebral body wall were observed at the caudal C6
intersection points were compiled in Table 4. Dl/rSIP had an and C7.

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 Cervical Anterior Transpedicular Screw Fixation

Discussion the region to accurately plan their surgical procedures [26,31].

This study helped to obtain necessary data and establish a baseline
Indications and advantages of ATPS for future clinical study of the surgical outcomes.
Transpedicular screw fixation is effective in the stabilization of Mimics software helps to create 3-D models from stacks of 2-D
the middle and lower cervical spine in cases of vertebral trauma, data which can accurately reflected the morphometry of the
fractures, deformities, and degenerative disorders. Of the numer- cervical region. Compared with conventional CT scan measure-
ous techniques for stabilizing the cervical spine, this fixation ment, the full size, shape and morphological variables of the
method confers superior pullout strength and constructs rigidity. pedicle can be directly determined using 3-D reconstruction
Abumi et al. [21] released a preliminary report on performing images. Complex and irregular structures of component elements
cervical transpedicular screw fixation for traumatic dislocations of cervical vertebrae-pedicle-lamina make conventional CT scan
and fractures of the middle and lower cervical spinal column. measurement difficult. During scanning, inaccuracy of measure-
However, quite a few patients needed multi-segment anterior ments is created by variable discrimination between bone and soft
decompression, and some also required long strut grafts or cages tissues or choosing the wrong middle layer. In contrast, Mimics is
for the reconstruction, thus, were biomechanically inferior and based on 3-D slicing segmentation. There is a better separation
vulnerable to failure, and subsequently revised [9]. Koller et al [8] delimiter and compensation for a certain degree of scanning
reported a high non-union rate of 20–50% and net failure rates of defects, which are based on the relationship between the data of
30–100% in multi-segment ACIF. The need for posterior gray values among slices and spatial location. Selection errors
supplemental stabilization was 10–15% in most studies that were made due to the lack of a holistic three dimensional view
reviewed multi-segment ACIF [22]. Posterior pedicle fixation for for selecting the narrowest pedicle on traditional CT scan. A
primary or metastatic cervical tumors or cervical osteoporosis with degree of cutting accuracy can be achieved by fitting the center
multi-segment fixation may enhance the stability and improve line of the pedicle of a 3-D model, measuring the center line of
fusion rates, but suffers with its own set of disadvantages. For curvature, and calculating the axial line, then cutting plane at
example, surgical morbidity and rates of infection increase. the three midpoints of the lines. Visual observation can be
Excessive intraoperative stripping of paraspinal muscles during rotated for vertebrae and middle cutting with sagittal or coronal
posterior cervical fixations can cause long-term neck pain. sections by measuring vertebral body and pedicle dimensions
Recently, several studies have been aimed at delineating the (Figures 2 and 3).
three-dimensional anatomy of the cervical pedicle and investigat-
ing the feasibility of transpedicular fixation in the subaxial cervical The anatomical character of ATPS related measurements
spine in an attempt to provide three-column fixation via one Morphometric measurements based on CT scans are more
approach [12,23–25]. Koller et al [12] reported a new concept efficient in determining pedicle dimensions than manual calliper
(ATPS) that combined the advantages of an anterior approach and measurements [23,25,32]. CT scans may be able to avoid possible
superior biomechanical characteristics of cervical pedicle screw deviations in disc height by post-mortem changes such as
fixation, with excellent results. There are, however, few clinical dehydration and altered tonus of the soft tissue [33]. Previous
reports since Koller’s reported [20,26]. Yukawa et al [20] found studies targeted areas at the coronal or sagittal planes for spiral CT
that postoperative lordosis improvement and early bony union [12,33,34]. Although it can display the character of the vertebral
occurred in all cases after ATPS. There were no serious anatomy, subjective selection error always appears due to
complications except for two cases of dysphagia at the final deficiency of scan precision and choice of target area. Mimics
follow-up (mean 12.2 months), and no pedicle perforation. The software is compatible with data of various types of machines (e.g.
author thought ATPS is useful in selected cases of multi-segmental CT or MRI) and 3-D reconstruction, region segmentation, output
anterior reconstruction of the cervical spine with adequate conversion, surface meshing, body meshing and processing,
familiarity and experience. Xu et al [26] developed ATPS for detailed data analysis for anthropometric templates, and osteot-
five patients with cervical fractures and dislocations in 2011. All of omy simulation can be viewed directly. The first step in screw
the screw placements were optimal and no pedicle screw placement for cervical pedicle fixation is to find an accurate
perforation was observed. There were no leakages of cerebrospinal entrance point. There are many measurements of cervical
fluid and incisions were healing at the final follow-up (mean 10.6 vertebrae and pedicles through different methods
months). There was no dysphagia in Xu’s study; the author [23,25,27,30,32]. Variability in the dimensions of cervical
thought the benefit was secondary to avoidance of abrasive drilling vertebrae are summarized in Tables S1 and S2 (electronic
part during the creation of an entrance point and also because of supplementary material), which compare our results with previous
deeper screw placement. studies [13,17,24–26,30,31,35].
In contrast to traditional anterior fixation, the surgery involving Vertebrae dimensions determine the operating space of ATPS,
ATPS is technically demanding because the margin of error while screw position in the transverse, vertical section and the width of
placing the screw is very narrow given its proximity to vital anterior plate. In our study, the mVBD ranged from 11.24 to
structures such as the vertebral artery, upper-lower intervertebral 21.93 mm in C3 to C7, similar to Koller [12] (13.83–21.60 mm),
disc and vulnerable neural and vascular structures [11,27,28]. Xu et al [26] (15.42–17.89 mm), and Liu et al [30] (16.88–
Therefore, a thorough 3-D understanding of the vertebrae and 19.53 mm). The ranges of mVBW was 15.67 to 32.78 mm and
pedicle morphology and regional anatomy is required for the had an increasing trend in C3 to C7 (Table 2), lower than Koller
accurate identification of the ideal pedicle screw entry, trajectory (18.13–50.62 mm). Compared with SH [17], the results of each
and screw size. There is substantial data on the pedicle anatomy level were greater in our measurements. aVBH provides screw
and various morphometric features of cervical vertebrae for the placement space in the vertical plane. Our results were (8.27–
western population [12,13,29]. Previous studies from Korea, the 17.01 mm) relative smaller, compared to Koller (11.70–
Indian subcontinent and studies from different regions (e.g. hip 32.45 mm) and Xu (14.65–16.00 mm). The results in our study
joints of Chinese population) have shown considerable variation showed that, although the cervical vertebrae are different from
from the western world [24,26,30]. There is paucity of similar data those in populations studied by Koller and Xu, there is still enough
on the Chinese population that will enable spinal surgeons from working space. These differences may have been caused by racial

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 Cervical Anterior Transpedicular Screw Fixation

differences or by variations or number of specimens. Statistically is 41 degrees in our results similar to Wang [31] (43.25 degrees)
significant differences in aVBH, mVBW and mVBD, which were but different from Koller [12] (48 degrees) and Xu [26] (47
also observed immerged data from both genders, similar to degrees). There was a decreasing tendency in C3 to C7 for TPA,
previous studies [17,30]. values in C3 to C5 were relatively consistent, but many differences
Pedicle anatomy for various races, gender and different levels were observed in C6 and C7 due to pedicle cohesion. The results
has shown to vary significantly. Liu et al [13] reported on the of TPA in our results are similar to previous studies in C3 to C5
measurements of 1311 partial and complete cervical spines using [12]. However, they vary for C6 and C7 and this could be due to
meta-analysis for different races comparisons. The results found racial differentiation and sample sizes. Based on these results, we
that significant differences between males and females existed at recommend placement of screws with TPA of 46.79–49.00 degrees
the outer pedicle width and height of C3 to C7 in the European/ in C3 to C5, and 40.89–32.26 degrees in C6 to C7 are
American population. There are more significant differences recommended for Chinese population.
comparing the cervical pedicles of males and females in the We measured the l/rSPA formed by the pedicle axis and a line
European/American population than that exists in the Asian drawn along the anterior vertebral body, as this angle would be
population (specifically in pedicle width and height). Our results that created between an ATPS and the anterior cervical plate, our
show that differences of OPW and OPH existed at C3 to C6 results are correspond to those reported in the literature [12,26].
between males and females which are similar to findings from Liu Kareikovic et al. [40] found that C3 pedicles were directed
et al study. The mean OPW and OPH in our results varied in the superiorly compared with the inferior endplate, that C4 and C5
middle-low cervical vertebrae with significant increases from pedicles were parallel to it, and that C6 and C7 pedicles were
cephalad C3 to caudad C7, ranging from 5.81–7.49 mm in width, inferiorly directed. In our study, lSPA and rSPA were lowest at the
and 7.77–8.69 mm in height, respectively (Tables 3), similar to the C3 level with a mean of 93.54 degrees, that is an ATPS would to
previous reports [31,36]. In the current study, there were no be directed slightly in cephalad direction in relation to the anterior
significant differences between left and right OPW and OPH, as vertebral cortex at C3. As mentioned, the OPH is mainly larger
has been reported in literature [37,38] and the OPW was found to than the OPW. Therefore, a steeper cephalad directed trajectory
be larger in males than in females [37,39]. Koller et al [12] for insertion of an ATPS is possible also at this level. In addition,
noted that pedicle height was greater than its width for both left the sagittal intersection points resembling the entry points of ATPS
and right pedicles of each vertebra, resembling similar at these and other levels might be chosen more caudal in reference
observations compared to our study. In the transpedicular to the superior endplate of the instrumented vertebra if necessary.
screw fixation technique, the dimensions of the screw are Therefore, the suggestion of SPA with 93.54–106.69 degrees in C3
critical. The rate of pedicle wall perforation and nerve root to C6, and 109.36–104.99 in C6 to C7 are recommended from
damage will increase when the pedicle diameter is less than our results.
4.5 mm [27]. Our results showed that the minimum diameter of Dl/rSIP had an increasing trend away from upper endplate
OPW was 4.41 mm in males and 4.22 mm in females (Table 3). (1.87–5.83 mm) and Dl/rTIP had a trend of contralateral turning
The results demonstrated that the pedicle might differ individ- ipsilateral in C3 to C7 (22.70,3.18 mm, Tables 4). With the
ually, so the dimensions of the screw should be appropriate for measurements of the distances of the sagittal and transverse
individual selection. Biomechanical tests show that the diameter intersections (l/rSIP and l/rTIP), we assessed the theoretical entry
of OPW suitable for rigid fixation is at least 3.5 mm. The points for ATPS in to the vertebral bodies and pedicles,
minimum value of OPW is larger than 4 mm in C3 to C5, and respectively. Due to midline crossing of the pedicle axis, insertion
5 mm in C6 to C7 signifying an easy placement of screws with of ATPS was unilaterally possible. Because lTIP and rTIP
defined trajectory. The decreasing trend of OPW lower than resemble the varying entry points for ATPS in the transverse
5 mm in C3 to C7 was lower than those reported by Chazono plane, a static or translational plate design will have to respect the
[39] and Kareijovic [40]. Taking into account the means and individual variations of entry points in the transverse and sagittal
calculating the frequencies depicts that ATPS fixation using planes, by adjusting the hole geometry and the distances between
3.5–4.0 mm diameter screws would be appropriate at all levels perforations at the center of the plate.
only in selected patients, but feasible in most of the
biomechanically challenged end-levels (C6–C7) of multilevel Future application of ATPS
cervical constructs. Another concomitant development that complements this study
For the mean PAL, Our mean values were 33.40–31.13 mm, is the use of computer assisted orthopedic surgery (CAOS) in these
similar to previous studies [12,13,26,31,36]. Compared to Wang surgeries. Accurate screw position was significantly improved with
[31], our results were probably more relevant and accurate due to the advent of CAOS. It helped to standardize optimal screw
our larger sample sizes. The biomechanical test also verified that placement and enabled minimally invasive approaches for
the screw head and length engaging at least two third of the surgeries (MIS). In recent years, a series of technological
pedicle had more advantages. So the pedicle axial length of 21– improvements have increased the accuracy rate of cervical screw
24 mm for C3 to C7 is recommended for both males and females. placement, mainly through the use of preoperative multislice spiral
We believe that safe transpedicular screw placement in the CT [12,23,24] and intraoperative navigation systems [41–43].
cervical spine depends on the selection of the entry point for screw Koller et al [20] analyzed the impact of using a navigation system
insertion and on proper orientation of the screw in the transverse on the accuracy of ATPS insertion and revealed an astonishingly
and sagittal plane. The risk of violating the transverse foramen or high accuracy for the ATPS group with no critical screw position
spinal canal and intervertebral disc will depend on the TPA and (0%) in axial or sagittal plane. This was far superior to the
SPA. Measuring the TPA using conventional imaging technique conventional unaided surgical technique that had a rate of
remains a challenge [30]. In one of the previous study, the TPA accuracy of 78.3% (coronal section) and 95.7% (vertical plane).
measured for pCPS insertion varies between a minimum mean of Kotani et al [44] completed a retrospective analysis of 180 pedicle
36 degrees for C7 pedicle and to a maximum mean of 49 degrees screws, and significant differences were found between 6.7% using
for C4 pedicle [40], larger than our results which showed TPA to CT and 1.2% using navigation system. Ito et al [45] found that in
be 32.26 for C7 to 46.79 degrees for C3. However, the mean value surgery on 171 cervical pedicles using a navigation system, the rate

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 Cervical Anterior Transpedicular Screw Fixation

of perforation was only 2.8%. In addition, technology based on Conclusions

Mimics could be used for rapid prototyping (RP) which might be
used synchronously to develop personalized navigation templates. This study provides valuable data for ATPS in the cervical spine
Fu et al [46] constructed a patient-specific biocompatible drill region for the Chinese population, suggesting that this technique is
template using Mimics which suite for anterior part of cervical also clinically possible in selected vertebrae and patients. Based on
vertebrae after 3D reconstruction. Combining with rapid proto- the results of this study, combined with a wide cancellous working
typing (RP) printing, the authors found that the screws in non- area inside the vertebral body [20], Morphological considerations
critical position were 44/48 (91.7%) and those in a critical position in favor of ATPS at C3 to C7 are as follows: The entrance points
were 4/48 (8.3%) after 3.5 mm-diameter screw insertion. These for pedicular screw insertion for C3 to C5 were recommended
personalized navigation templates will avoid the disadvantages of 22,23 mm from the median sagittal plane, 1–4 mm from the
CAOS, particularly increased surgical time, steep learning curve upper endplate, with TPA being 46.79–49.00 degrees and SPA
and cost. being 93.54–106.69 degrees. The entry points in the ipsilateral
Although ATPS is a three-column fixation device that could be pedicle for the screws for C6 and C7 were 0–4 mm from the
a valuable tool in a surgeon’s armamentarium compared to other median sagittal plane, 5–6 mm from the upper endplate, with
methods, the authors think that only surgeons experienced in TPA being 40.89–32.26 degrees and SPA being 109.36–104.99
transpedicular screw fixation and surgery of the cervical spine degrees. The pedicle screw insertion diameter was recommended
should perform this method of instrumentation. Thus, conven- 3.5 mm (C3 and C4), 4.0 mm (C5 to C7), and the pedicle axial
tional methods of inserting pedicle screws are still important for a length was 21–24 mm for C3 to C7 for both males and females.
safe and current procedure, particularly for the use of LMS which Nevertheless, it appears to us that morphological guidelines are
is most frequently performed for comprehensive clinical practice in not sufficient to provide safe space for C3 and should be
posterior cervical instrumentation [2,7,47–49]. individualized given its relatively smaller anatomy structure.

Limitations of this study Supporting Information

Although this study has several impacts, there are some
Table S1 Summary of previous studies (Part 1).
limitations. First, it may be pointed out that the sample size in
our study was relatively small; however, the statistical analyses (DOC)
have brought out significant outcomes with a scientific basis. Table S2 Summary of previous studies (Part2).
Second, due to limitations of the function of Mimics software, (DOC)
although the axial line of the pedicle can be calculated by fitting,
artificial selection was also needed for ensuring the optimal screw Acknowledgments
placement in the narrowest part of the pedicle. More advanced
techniques like rapid prototyping may be used in conjunction with The authors thank Zhihua Han from the An Hui Medical University for
Mimics to develop real 3-D models for surgical simulation. Third, discussion of the project.
all the inputs were from CT scan DICOM data that are subject to
slice thickness, slice interval, and may have some effect on actual Author Contributions
processing by Mimics. Lastly, as this study is largely anatomical Conceived and designed the experiments: CC JO DR. Performed the
and morphometric, it is not a substitute to surgical and clinical experiments: CC PDS CFW WDW. Analyzed the data: CC. Contributed
acumen [20,26]. reagents/materials/analysis tools: YZZ JGW SL. Wrote the paper: CC.

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