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CT SEMIOTICS OF VERTEBRAE IN PATIENTS WITH
CERVICAL SPINAL STENOSIS
Parvoz Abdulhakimov
Samarkand state medical university, Samarkand, Uzbekistan
https://doi.org/10.5281/zenodo.15920376
ARTICLE INFO
ABSTRACT
Received: 08
th
July 2025
Accepted: 14
th
July 2025
Online: 15
th
July 2025
,
Introduction.
The number of surgical interventions on the
cervical spine due to stenosis is constantly increasing, which
justifies the need for careful preoperative preparation, taking
into account the complexity of the intervention and the age of
the patients.
The purpose of the work
is to justify the need to include in the
algorithm for processing CT data the density of bone tissue of the
vertebral bodies and arches to assess its quality when planning
osteoplastic decompressive surgery. Laminoplasty in patients
with cervical spine stenosis against the background of
degenerative-dystrophic changes.
Materials and methods.
Single-center retrospective study.
Qualitative and quantitative characteristics of the spine were
studied using radiography and multislice computed tomography
(MSCT) in 82 patients with degenerative-dystrophic diseases of
the cervical spine with spinal canal stenosis (SCS).
Results.
The data obtained indicate a tendency to increase the
overall density of the cervical vertebrae from CIII to CV and to
decrease it more caudally with a minimum density for CVII
without signs of osteoporosis. A similar tendency is
characteristic of the trabecular bone. The density of the osteon
layer of the cortical plate of the vertebral arch significantly
differs from the density of the outer and inner plates. The total
density of the compact layer of the cortical plate of the vertebral
arch exceeds (785.15 ± 38.4) HU.
Discussion.
In patients with degenerative-dystrophic changes
in the spine, the assessment of the density of various structural
formations of the vertebrae according to CT data should be
given the greatest importance. First of all, bone density
assessment becomes increasingly important with the age
of patients. Determining the bone quality is crucial for the
success of treatment, but it is also part of the optimal surgical
preparation for spinal surgery.
KEYWORDS
Spine,
cervical
spine,
stenosis, semiotics, CT
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INTRODUCTION
Modern imaging techniques provide excellent anatomical images of the cervical spine.
The choice of each depends on the clinical scenario and therapeutic alternatives.
Multipositional radiography still remains a fundamental method, as it allows for evaluation of
the spinal axis, vertebral dimensions and changes, and for follow-up after treatment, being cost-
effective and visually justified examination [1–3]. The role of MRI has significantly increased,
allowing visualization of soft tissue structures of the spine, including intervertebral discs,
ligaments, spinal cord, in particular, its mobility, which is extremely important for patients with
cervical spinal stenosis (CSSS) complicated by myelopathy [2, 4–8]. No less importance is
attached to multislice computed tomography (MSCT) in the study of degenerative changes in
the spine due to its high spatial resolution and unique ability to qualitatively and quantitatively
assess the condition of the vertebrae, both before treatment and at its various stages [2, 9, 10].
A set of radiation diagnostic methods is often used to assess the results of treatment of patients
with CSSS [2, 11]. The study of the anatomy of the vertebrae, their architecture, and density
indices is extremely important for deciding on the choice of treatment method for any type of
surgical intervention on the spine, including the elimination of cervical spinal stenosis (CSSS).
Determining the quality of the bone is of crucial importance for the success of treatment in
many cases, but it is also part of optimal surgical preparation for spinal surgery [12, 13]. First
of all, this concerns the assessment of the bone condition for the introduction of implants for
various types of transpedicular fixation and other methods of metal osteosynthesis in order to
prevent various complications associated with malposition of screws or other structures,
failure of metal structures, and more attention should be paid to patients with pronounced
degenerative changes in density indices (HU) [14–16]. Bone density, as an important strength
factor, is determined by various methods, but the most common and universal is MSCT using
standardized Hounsfield units (HU), providing a reliable assessment of bone density, improving
diagnostic indicators [10, 18, 19]. The study of the anatomy, architecture, and density of the
vertebrae is carried out using individual methods or in a complex, as in the work of G. Schröder
et al., where micro-CT and MSCT were used [12]. Histomorphometric study (the “gold standard”
for studying bone quality) in the work of HJ Grote et al. was used to assess trabecular bone
density [20]. In cases where CT is used, cancellous bone density in HU is determined for the C2–
C7 vertebrae on each sagittal, coronal and axial CT image, and cervical spine (CS) computed
tomography results provide reliable information regardless of the plane of measurement, age
or gender, and the degree of degeneration [21]. According to Q. Zaidi et al., O.N. Leonova et al.,
in patients with degenerative-dystrophic changes in the spine, the greatest importance should
be attached to the assessment of the density of various structural formations of the vertebrae
according to MSCT data [15, 22]. In the literature presented above, concerning the
determination of the quality of the vertebral bone based on bone density according to MSCT
data, only some indicators and parameters of the vertebral div have been studied, and when
measuring mainly the local density of spongy bone. However, it is important to know the state
of all structural formations of the vertebra, especially when using the laminoplasty method,
where the most important anatomical zones for the surgeon are the vertebral arches and facet
joints, as the main objects to which the plates are fixed. The purpose of the work is to
substantiate the need to include in the algorithm for processing MSCT data the density of bone
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tissue of the vertebral bodies and arches to assess its quality when planning osteoplastic
decompressive surgery laminoplasty in patients with cervical spinal stenosis against the
background of degenerative-dystrophic changes.
MATERIALS AND METHODS
A single-center retrospective study was performed at the neurosurgical department No.
3 Federal Center of Neurosurgery (Tyumen). Qualitative and quantitative characteristics of the
spine were studied using radiography and MSCT methods in 82 patients with degenerative -
dystrophic diseases of the cervical spine with spinal canal stenosis. Level of evidence - IV.
Clinical and statistical characteristics of patients The presented sample was dominated by
males (86.6%) aged 56 to 75 years (70.7%). The majority of patients (89.0%) had multilevel
spinal stenosis (Table 1). During surgery, cervical laminoplasty was performed at the CIII–CVI
and CIII–CVII levels in 68.3% of patients.
Research methods
1. Multipositional and functional radiography was performed on all 82 patients.
2. Multislice spiral computed tomography (MSCT) was performed on all 82 patients using
an Aquilion X-ray computed tomograph One (1385 Shmoishigami, Otawara-shi, Tochigi 324-
8550, Japan, 320 detector lines, maximum number of slices — 640). MSCT was used to assess
bone quality (density, structure, size of the vertebral div and arches). Vertebral density was
measured on axial and sagittal slices (total density, density of spongy bone, compact layer). The
density of the cortical plate of the vertebral arch was studied in different layers. When
necessary, 3D reconstructions were performed (Fig. 1). Inclusion criteria: 1) cervical spine
stenosis according to MSCT and MRI data, complete radiation archive; 2) no history of cervical
spine surgeries in the patients' anamnesis; 3) patients' consent to publication of the data
obtained during the study, without personal identification. The study was carried out in
accordance with the ethical standards of the Helsinki Declaration of the World Medical
Association as amended by the Ministry of Health. All patients signed informed consent for the
publication of data without personal identification. To confirm the conclusions about the
differences between the results obtained in the two groups, taking into account the small
samples, the Mann-Whitney U-test was used. The sample parameters given in the tables below
had the following designations: M is the mean, σ is the standard root-mean-square deviation, n
is the number of patients, p is the achieved significance level. The critical significance level
when testing statistical hypotheses in this study was taken to be 0.05.
RESULTS
The study of the total density of the vertebrae from CIII to CVII in the sagittal plane
showed its increase from the level of CIII to CIV, and from the level of CV and caudally a decrease
in the indices in descending order with a minimum at the level of CVII was noted. Measurement
of the density of the compact layer of the vertebral div in the sagittal plane along the anterior
and posterior surfaces showed that the density of the compact layer of bone tissue was higher
in the posterior parts of the vertebral bodies compared to the anterior ones, but without
reliable differences. This is due to the fact that the boundaries of the compact layer and
trabecular bone on axial sections are clearly visualized, whereas in the sagittal plane the
boundaries are determined conditionally. When studying the density of the compact layer of
the cervical vertebrae along the anterior and posterior surfaces in axial density the differences
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are reliable, except for CVII. As for the CVII vertebra, it had minimal density with resorption
zones and minimal differences on the anterior and posterior surfaces, due to which the density
indicators did not differ.
The local total and point density of the three layers of the cortical plate was also studied,
since the density of the osteonic (central) layer was much higher than the density of the outer
and inner plates, which must be taken into account during preoperative measurement of the
density of the vertebral arch to which the plates are fixed during laminoplasty.
Statistical data on the density of different layers of the cortical plate of the
vertebral arch are shown in Figure 4. The density of the osteon layer is 33.3% higher
than the density of the inner plates and 10.4% higher than the density of the outer plates. This
should be taken into account when measuring the density of the cortical plate of the arch. When
measuring in the area of the inner plates, the layer of which is thinner than the osteon layer,
very low density values can be obtained. It is necessary to measure the density of all layers not
only pointwise, but also by determining the local total density of all layers of the cortical plate,
which was measured in the zone of interest in the form of a circle capturing the entire thickness
of the cortical plate (ROI = 1.5–2.2 cm2). The local density of all layers of the cortical plate of
the vertebral arch varied from 700 to 1150 HU, averaging (785.15 ± 38.4) HU, with the density
in the zone adjacent to the facet joints being somewhat higher in 75.6% of patients.
Measurement of the thickness of the vertebral arches in the axial plane at an equal distance
from the central axis of the vertebra revealed that in 83% of patients this indicator differed on
the right and left, with the thickness being smaller on the right in 45% of patients.
DISCUSSION
The use of MSCT allowed us to determine not only the nature and prevalence of changes
in the spine, but also to study the quantitative density characteristics of the vertebrae in SSOP,
which allowed us to objectively judge the state of trabecular and compact bone tissue when
assessed in Hounsfield units (HU). This conclusion is confirmed by the studies of A.N. Mikhailov,
T.N. Lukyanenko [23]. In the work of G. Schröder et al . using micro-CT and MSCT in all
examined patients, the density of cancellous bone was significantly higher in the cervical
vertebrae (mean 177.6 HU) than in the thoracic (mean 94.4 HU) or lumbar vertebrae (mean
62.8 HU, p < 0.001). In our study, the density of the vertebrae in the cervical region was
significantly higher than in the presented data. This is due to the fact that in the cited work,
patients with one or two vertebral fractures at the age of (84.3 ± 8.4) years were examined,
whereas in our sample the average age did not exceed (58.9 ± 7.9) years, and there were no
patients with vertebral fractures. In addition, we studied the trabecular bone density over the
entire area of the vertebra in the axial plane, whereas the authors studied a small area in the
center of the vertebra, which did not always reflect the overall density [24]. Histomorphometric
study (the " gold standard " for studying bone quality) HJ Grote et al . found that the trabecular
bone density in the cervical spine is significantly higher than in the thoracic or lumbar spine
[20]. It was shown that bone loss in the cervical spine with age is less than in other parts
of the spine. No significant age-related loss of trabecular density was noted in the CIII and CIV
cervical vertebrae, which is consistent with the data of G. Schröder et al. [24, 25]. In studies
using CT, the density of cancellous bone in HU was determined for the CII–CVI vertebrae on
each sagittal, coronal and axial CT image [21]. According to the authors, the average density
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values in units The Hounsfield (HU) values, which can be attributed to osteopenia and
osteoporosis, were (284.0 ± 63.3) and (231.5 ± 52.8), respectively. The density indices of the
two upper cervical vertebrae (CII and CIII) had a higher density than for other segments [21].
According to our data, the trabecular density of the vertebrae was much higher, averaging
(387.89 ± 49.14) to (333.81 ± 46.09) for CIII–CVI. We also studied the density of different layers
of the cortical plate of the vertebral arch, which is an important object of the surgical scenario.
The highest density corresponded to the osteonic layer, which coincides with the data of G.V.
Dyachkova et al. [26]. The local density of all layers of the cortical plate of the vertebral arch
varied from 700 to 1150 HU, averaging (785.15 ± 38.4) HU. According to Q. Zaidi et al ., in
patients with degenerative-dystrophic changes in the spine, the greatest importance should be
attached to the assessment of the density of various structural formations of the vertebrae
using MSCT data [ 15 ]. First of all, the assessment of bone density becomes increasingly
important with the age of patients. Determination of bone quality is crucial for the success of
treatment, especially the prevention of osteoporotic fractures, but it is also part of optimal
surgical preparation for spinal surgery and monitoring the condition of screws [24, 27]. The
data obtained indicate a tendency for the overall density of the cervical vertebrae to increase
from CIII to CV and decrease further caudally with minimal density for CVII without signs of
osteoporosis. A similar trend is characteristic of the trabecular bone. According to X. Liang et al
., it is necessary to determine not only the overall and local density of the vertebrae, but also to
study it at three levels in the sagittal plane (upper third , central part, lower third) to clarify the
effect of disc degeneration on the density of the vertebra [28]. Reliable differences in the density
of compact bone along the posterior surface of the CIII–CV vertebrae were revealed on axial
sections. There is a moderate asymmetry in the thickness of the vertebral arch on axial sections.
The density of the osteon layer of the cortical plate of the vertebral arch differs significantly
from the density of the outer and inner plates. The overall density of the compact layer of the
cortical plate of the vertebral arch exceeds 785.15 ± 38.4 HU, which indicates sufficient density
of the vertebral arch, taking into account all its layers, for the safe insertion of fixing screws.
CONCLUSION
The obtained data substantiate the need to include in the MSCT data processing algorithm
the study of the density of the vertebral bodies, the vertebral arch, its thickness for developing
a plan for surgical intervention in patients with cervical spinal stenosis, since they allow
obtaining an objective characteristic of bone quality.
References:
1.
Damdinov B.B., Sorokovikov V.A., Larionov S.N., et al. Features of changes in the sagittal
balance of the cervical spine in cervicobrachial syndrome. Spine surgery. 2019;16(2):42-48.
doi: 10.14531/ ss2019.2.42-48
2.
Spirig JM, Sutter R, Götschi T, et al. Value of standard radiographs, computed tomography,
and magnetic resonance imaging of the lumbar spine in detection of intraoperatively confirmed
pedicle screw loosening—a prospective clinical trial. Spine J. 2019;19 (3):461-468. doi:
10.1016/j.spinee.2018.06.345
3.
Hirai T, Yoshii T, Sakai K, et al. Long-term results of a prospective study of anterior
decompression with fusionand posterior decompression with laminoplasty for treatment of
EURASIAN JOURNAL OF MEDICAL AND
NATURAL SCIENCES
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IF = 7.921
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cervical
spondylotic
myelopathy.
J
Orthop
Sci.
2018;23(1):32-38.
doi:
10.1016/j.jos.2017.07.012
4.
Wolf K, Krafft AJ, Egger K, et al. Assessment of spinal cord motion as a new diagnostic MRI-
parameter in cervical spinal canal stenosis: study protocol on a prospective longitudinal trial. J
Orthop Surg Res. 2019 ;14 (1):321. doi: 10.1186/ s13018-019-1381-9
5.
Hesni S, Baxter D, Saifuddin A. The imaging of cervical spondylotic myeloradiculopathy.
Skeletal Radiol. 2023;52 (12):2341-2365. doi: 10.1007/s00256-023-04329-0
6.
Tetreault L, Kalsi-Ryan S, Davies B, et al. Degenerative Cervical Myelopathy: A Practical
Approach
to
Diagnosis.
Global
Spine
J.
2022
;12
(8):1881-1893.
doi:
10.1177/21925682211072847
7.
Chen YC, Kuo CH, Cheng CM, Wu JC. Recent advances in the management of cervical
spondylotic myelopathy: bibliometric analysis and surgical perspectives. J Neurosurg Spine.
2019;31 (3):299-309. doi: 10.3171/2019.5. SPINE18769
8.
Nouri A, Cheng JS, Davies B, et al. Degenerative Cervical Myelopathy: A Brief Review of
Past Perspectives, Present Developments, and Future Directions. J Clin Med. 2020;9 (2):535.
doi: 10.3390/jcm9020535
9.
Llopis E, Belloch E, León JP, et al. The degenerative cervical spine. Radiologia. 2016 ;58
Suppl 1:13-25. doi: 10.1016/j.rx.2015
10.
Xu F, Zou D, Li W, et al. Hounsfield units of the vertebral div and pedicle as predictors of
pedicle screw loosening afterdegenerative lumbar spine surgery. Neurosurg Focus. 2020;49
(2):E10. doi 10.3171/2020.5. FOCUS20249
11.
Liu FJ, Ding XK, Chai Y, et al. Influence of fixed titanium plate position on the effectiveness
of open-door laminoplasty for cervical spondylotic myelopathy. J Orthop Surg Res. 2022 ;17
(1):297. doi: 10.1186/s13018-022-03188-0
12.
Schröder G, Reichel M, Spiegel S, et al. Breaking strength and bone microarchitecture in
osteoporosis: a biomechanical approximation based on load tests in 104 human vertebrae from
the cervical, thoracic, and lumbar spines of 13 div donors. J Orthop Surg Res. 2022 ;17 (1):228.
doi: 10.1186/s13018-022-03105-5
13.
Kim MK, Cho HJ, Kwak DS, You SH. Characteristics of regional bone quality in cervical
vertebrae considering BMD: Determining a safe trajectory for cervical pedicle screw fixation. J
Orthop Res. 2018 ;36 (1):217-223. doi: 10.1002/jor.23633
14.
Zeynalov Yu . L., Dyachkova G. V., Burtsev A. V. and dr. Computed tomographic semiotics
of apical vertebrae in patients with idiopathic scoliosis aged 14 to 18 years depending on the
magnitude of spinal deformity. Radiology – practice. 2021; (5):11-27. doi: 10.52560/2713-
0118-2021-5-11-27
15.
Zaidi Q, Danisa OA, Cheng W. Measurement Techniques and Utility of Hounsfield Unit
Values for Assessment of Bone Quality Prior to Spinal Instrumentation: A Review of Current
Literature.
Spine
(Phila
Pa
1976).
2019
;44
(4):
E239-E244.
doi:
10.1097/BRS.0000000000002813
16.
Han C, Zhou C, Zhang H, et al. Evaluation of bone mineral density in adolescent idiopathic
scoliosis using a three-dimensional finite element model: a retrospective study. J Orthop Surg
Res. 2023 ;18 (1):938. doi: 10.1186/s13018-023-04413-0
EURASIAN JOURNAL OF MEDICAL AND
NATURAL SCIENCES
Innovative Academy Research Support Center
IF = 7.921
Volume 5 Issue 7, July 2025 ISSN 2181-287X
Page 50
17.
Weinberg DS, Rhee JM. Cervical laminoplasty: indication, technique, complications. J Spine
Surg. 2020 ;6 (1):290-301. doi: 10.21037/jss.2020.01.05
18.
Choi MK, Kim SM, Lim JK. Diagnostic efficacy of Hounsfield units in spine CT for the
assessment of real bone mineral density of degenerative spine: correlation study between T-
scores determined by DEXA scan and Hounsfield units from CT. Acta Neurochir (Wien). 2016
;158 (7):1421-1427. doi: 10.1007/s00701-016-2821-5
19.
Wang H, Zou D, Sun Z, et al. Hounsfield Unit for Assessing Vertebral Bone Quality and
Asymmetrical Vertebral Degeneration in Degenerative Lumbar Scoliosis. Spine (Phila Pa 1976).
2020 ;45 (22):1559-1566. doi: 10.1097/ BRS.0000000000003639
20.
Grote HJ, Amling M, Vogel M, et al. Intervertebral variation in trabecular microarchitecture
throughout the normal spine in relation to age. Bone. 1995 ;16 (3):301-308. doi: 10.1016/8756-
3282(94)00042-5
21.
Han K, You ST, Lee HJ, et al. Hounsfield unit measurement method and related factors that
most appropriately reflect bone mineral density on cervical spine computed tomography.
Skeletal Radiol. 2022;51(10):1987–1993. doi: 10.1007/ s00256-022-04050-4
22.
Leonova ON, Baikov ES, Krutko AV. Features of bone density of the lumbar vertebrae in
patients with degenerative diseases of the spine. Genius of Orthopedics. 2022;28(5):692–697.
doi: 10.18019/ 1028-4427-2022-28-5-692-697. EDN: EUHAVU.
23.
Mikhailov AN, Lukyanenko TN. Mineral density of the vertebrae in patients with cervical
osteochondrosis according to quantitative computed tomography. International Reviews:
Clinical Practice and Health. 2014;(6):24-32.
24.
Schröder G, Jabke B, Schulze M, et al. A comparison, using X-ray micro-computed
tomography, of the architecture of cancellous bone from the cervical, thoracic and lumbar spine
using 240 vertebral bodies from 10 div donors. Anat Cell Biol. 2021;54(1):25-34. doi:
10.5115/acb.20.269
25.
Schröder G, Wendig D, Jabke B, et al. Comparison of the spongiosa morphology of the
human cervical spine (CS), thoracic spine (TS) and lumbar spine (LS) of a 102-year-old div
donor. Osteology. 2019;28(04):283-288. (In German) doi: 10.1055/a-0997-8059
26.
Dyachkov KA, Dyachkova GV, Kutikov SA Method for determining the local density of the
cortical plate of long bones. Russian Federation Patent for Invention No. 2539424. 20.01.15.
Bulletin No. 2. Available at: https://www.fips.ru/registers-doc-view/fips_servlet. Link active
on 07.02.2024.
27.
Wu X, Shi J, Wu J, et al. Pedicle screw loosening: the value of radiological imaging and the
identification of risk factors assessed by extraction torque during screw removal surgery. J
Orthop Surg Res. 2019 ;14 (1):6. doi: 10.1186/s13018-018-1046-0
28.
Liang X, Liu Q, Xu J, et al. Hounsfield Unit for Assessing Bone Mineral Density Distribution
Within Cervical Vertebrae and Its Correlation With the Intervertebral Disc Degeneration. Front
Endocrinol (Lausanne). 2022;13:920167. doi: 10.3389/fendo.2022.920167
