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MORPHOMETRIC STUDY OF LUMBAR VERTEBRAE IN CENTRAL INDIAN POPULATION AND ITS CLINICAL IMPORTANCE.

BACKGROUND

Human spine with its distinctive curves is an adaptation to bipedal gait and it becomes a weight bearing column. [1] The vertebral body is the key element in the load-bearing system of the spine. [2] This is highlighted by the observation that vertebral centrum size increases craniocaudally. [3] This is partially responsible for the decreased incidence of fractures of the lower lumbar spine. In the lumbar region, the significant deviations are a tendency for dorsal heights of the lower lumbar vertebral bodies to decrease below L2. [4] Lumbar vertebra has kidney shaped body, wider transversely than the anteroposterior depth and height. The fifth lumbar vertebra is a transitional vertebra and differs from the rest of the lumbar vertebrae, in that it has a wedge shaped body [5] which is the largest and is markedly deeper anteriorly. [6]

Dimensions of lumbar vertebrae hold great relevance in clinical diagnosis of lower backache. Population specific variations are common in many body dimensions of lumbar vertebrae. [7] Knowledge of lumbar morphometry is vital not only for the understanding of biomechanics of lumbar spine, but also for various interventions aimed at its stabilisation and correction of deformities, [8] which is essential for the spinal implants design, lumbar decompression surgery and workspace definition for robot-assisted surgery. [9]

Morphometric studies published by many authors have established that the vertebrae undergo continuous growth and remodelling throughout life, presumably in response to the changing needs of the body. [10] It is also important to distinguish differences in morphometry of vertebrae in males and females and to understand changes in the elderly persons, as incorrect placement of instruments and devices may have serious complications. [8] The morphological changes of the vertebrae associated with normal aging are still subject of debate, whereas this knowledge is important in detecting vertebral fractures and degenerative shape changes. [9] Sex can be estimated from first lumbar vertebra with reasonable accuracy in medico-legal cases when skeletal remains are incomplete. [11]

MATERIALS AND METHODS

This is a retrospective descriptive study. The present work has been carried out in the Department of Anatomy and Radiodiagnosis, SAMC and PGI, Indore.

The Material Comprised of 2 Groups

1. Ten Cadavers (40-60 yrs.) available in the Department of Anatomy.

2. 120 Lateral view digital x-rays of normal adults (60 males and 60 females divided into 3 age groups).

Objective

The present study is to measure morphometry of lumbar vertebrae in Central Indians.

A. Cadaveric Study

Ten adult cadavers fixed in 10% formalin in the Department of Anatomy, Sri Aurobindo Medical College and PG Institute, Indore, were used for the present study. The cadavers were in the age group of 40-60 years. Lumbar region along with lumbosacral junction was dissected. After removing all the viscera, the muscles of posterior abdominal wall were exposed. Psoas major was dissected out carefully from intervertebral discs and vertebral bodies. The abdominal aorta and inferior vena cava were also removed from the front of the vertebral column, so as to expose the front of vertebrae and the intervertebral discs. The lumbosacral part of the vertebral column was separated in one piece by using a saw. These specimens contained the vertebral bodies and intervertebral discs from the upper border of L1 to the lower border of L5 along with sacrum and the 2 hip bones. Median section was cut by an electric saw. The anterior and posterior heights of bodies of lumbar vertebrae were measured using Digital Vernier Caliper (Fig. 1). The average was calculated and tabulated (Table 1).

B. Radiological Study

120 (lateral view) digital radiographs of normal healthy adults were obtained from the Department of Radiodiagnosis of Sri Aurobindo Medical College and PG Institute, Indore. Ethical clearance was taken from the Institutional Ethical Committee.

These Adults were in the Age Group of 21 to 50 Years of both Sexes. Observations were recorded by Forming SubGroups-

1. Age Group I: 21-30 years.

2. Age Group II: 31-40 years.

3. Age Group III: 41-50 years.

Each age group comprised of 40 cases, of which 20 were males and 20 were females.

In all Lateral Radiographs (Digitalised)

Anterior and posterior heights of vertebral bodies were directly measured digitally (Fig. 2), and the average and standard deviation were calculated. The values so obtained were put to statistical tests and tabulated (Table 2 and 3).

Statistical Analysis

The obtained data was tabulated and analysed for descriptive statistics. The average and standard deviation of the above-mentioned parameters were calculated and recorded. OneWay ANOVA was used. The association of vertebral body dimensions with age was calculated using Analysis of Variance (ANOVA). A significance level of P < 0.05 was used. Student's t-test was used to analyse the significance of gender differences. P < 0.05 (Significant).

RESULTS

In Cadavers

The anterior and posterior heights of bodies of lumbar vertebrae were measured by Digital Vernier Caliper. Observations were recorded, and their average was tabulated (Table 1). The average anterior height in centimetres were: L1- 2.15, L2- 2.26, L3- 2.38, L4- 2.25, L5- 2.34 and the average posterior heights in centimetres were: L1- 2.37, L2- 2.46, L3-2.40, L4- 2.30, L5- 2.12. From these readings, it is concluded that in cadavers

* Average anterior height < posterior height except at L5.

* Average anterior height increases from L1 to L3, decreases at L4 and increases again at L5.

* Average posterior height increases up to L2.

On Digital X-Rays

The anterior and posterior heights of lumbar vertebral bodies were measured digitally as seen in Fig. 2. Average and standard deviation was calculated. In total 120 radiographs, (Table 2) the average anterior height in centimetres were L1- 2.79, L2 and L3- 2.93, L4- 2.92, L5- 2.93 and the average posterior height in centimetres were L1- 2.98, L2- 3.06, L33.07, L4- 2.90 and L5- 2.72.

From these Readings, it is concluded that

* Average anterior height < posterior height except at L4 and L5.

* Average anterior height increases from L1 to L3, decreases at L4 and increases again at L5.

* Average posterior height increases upto L3.

The observations were divided into 3 subgroups according to age (Table 2). Each age group was further divided gender wise (Table 3). Average and standard deviation was calculated.

From these Readings, it is concluded that 1. Average anterior height < Posterior height upto L3 in all the age groups and in both sexes except in Age Group III in females where average anterior height < posterior height was upto L4.

2. Average anterior height in-

Group I

Males- It increases from L1 to L5.

Females- It increases upto L2, then decreases upto L4 and increases again at L5.

In Group II and III

Males- It increases upto L3, decreases at L4, increases at L5. Females- It increases upto L2 and then decreases upto L5.

Average Posterior Height in-Group I

* Males- It increases upto L3.

* Females- It increases upto L2.

Group II: In both the sexes, it increases upto L3. Group III: It increases upto L2 in both the sexes.

Statistical Inferences

P value < 0.05 (significant) analysed by ANOVA (Table 2).

Analysis by ANOVA revealed non-significant association between anterior and posterior heights of bodies of all the lumbar vertebrae in various age groups.

P-value < 0.05 (Significant) analysed by Independent t-test (Table 3).

It is revealed that there is significant association between gender and anterior heights of bodies of 4th (P= 0.003) and 5th (P= 0.003) lumbar vertebrae in Age Group-I. In the same age group, there is significant association between gender and posterior heights of bodies of all the lumbar vertebrae (P value for L1= 0.033, L2 and L3= 0.002, L4 and L5= 0.000).

Similarly, significant association was seen between gender and anterior height of body of 5th (P= 0.010) lumbar vertebra in Group-III (41-50 yrs.). In the same age group, there was significant association between gender and posterior height of body of 1st (P= 0.033) lumbar vertebra.

DISCUSSION

According to El Sayed et al (2014), [12] low back pain is one of the most frequently observed symptoms in the human musculoskeletal system. The results of morphometry of lumbar vertebral bodies offer a guidance to clinicians for the evaluation and management of subjects complaining of low back pain in order to propose specific preventive or rehabilitation protocols.

Mavrych et al (2014) [9] in a study on lumbar vertebrae of 212 cadavers (0-90 yrs.) have concluded that measurements of vertebral body heights indicated a most rapid growth of anterior height of L3, one of the factors that contributes to the lumbar curve formation. Their results showed a slight decrease in vertebral body heights in senior persons due to osteopenia.

Mavrych et al (2014), [9] citing the work of Gilad et al (1985) and Diacinti et al (2010, 2011) stated that they are of the same opinion; while Castillo et al (1998) and Masharawi et al (2008) expressed that decrease in human height with aging results from a decrease in the thickness of the intervertebral discs only. We have also found the same results as that of Mavrych et al (2014) [9] with advancing age in Group III (41-50 yrs.). Their results showed a statistically significant correlation between all vertebral body dimensions and age for both men and women. This is in contrast with earlier studies by Masharawi et al (2008), who did not find such a correlation. The contrasting findings were possibly due to their larger sample size and the age groups used in their study (age range 0-90 years vs. 20-80 years). In our study, Analysis by ANOVA revealed non-significant association between anterior and posterior heights of bodies of all the lumbar vertebrae in various age groups.

According to Mavrych et al (2014), [9] there was no sexual dimorphism in measurements of lumbar vertebral bodies (P>0.05). As cited by them, Gilsanz et al (1994) and GocmenMas et al (2010) opine the same. But in the present study, in Group-I (21-30 yrs.), it is revealed that there is significant association between gender and anterior heights of bodies of 4th (P= 0.003) and 5th (P= 0.003) lumbar vertebrae. In the same age group, there is significant association between gender and posterior heights of bodies of all the lumbar vertebrae (P value for L1= 0.033, L2 and L3= 0.002, L4 and L5= 0.000). Similarly, in Group-III (41-50 yrs.), significant association was seen between gender and anterior height of body of 5th (P= 0.010) lumbar vertebra. In the same age group, significant association was found between gender and posterior height of body of 1st (P= 0.033) lumbar vertebra.

Regarding the anterior heights of bodies of lumbar vertebrae, Gocmen-Mas et al (2010) [10] on Anatolians recorded (on MRI), smaller values than the present values in females, while El Sayed et al (2014) [12] in Lebanese adult females recorded (on plain radiographs) greater values than the present ones in females. However, their results showed a gradual cephalocaudal increase, but we found such increase only upto L2 in females. Posterior heights of lumbar vertebral bodies recorded by El Sayed et al (2014) [12] are also greater than the present ones, but these values showed craniocaudal increase only upto L2 as found in our study.

In a study on 24 subjects by Abuzayed et al (2010), [13] the anterior height of the vertebral body was smallest at the L4 level (26.2 mm) and largest at the L5 level (28.5 mm). The anterior height showed an increase from the L1 to L5 level, except for a decrease at the L4 level. In our radiographic study, smallest anterior height is at L1 (27.9 mm) and largest is at L2, L3 and L5 (29.3 mm). Our study also shows a decrease at L4. In their study, the posterior height of the vertebral body was smallest at the L5 level (22.9 mm) and largest at the L2 and L3 levels (27.3 mm). It showed a gradual increase from the L1 to the L2 and L3 levels, and then decreased towards the L5 level. We also got similar results with different values, the smallest posterior height at L5 being 27.2 mm and largest at L3 being 30.7 mm. In their study, the anterior height of the vertebral bodies was smaller than the posterior height at the L1 and L2 levels, same as the posterior height at the L3 and L4 levels, and larger than the posterior height at the L5 level. But we found anterior heights smaller than the posterior upto L3 and the reverse at L4 and L5. According to Hegazy et al (2014), [14] the compressive loads occur more on the posterior concave aspects, particularly of lower lumbar segments resulting in decrease in the posterior heights. Gocmen-Mas et al (2010), [10] Hegazy et al (2014) [14] and Abuzayed et al (2010), [13] the values found in their study are smaller than those found in our study. These normal figures could also be of forensic importance because of the observed racial, ethnic and regional variations. [12]

Referring to the work of Vialle et al (2005), Hegazy et al (2014) [14] have said that lumbar lordosis is formed by wedging of the lumbar vertebral bodies and of the intervertebral discs. Hegazy et al (2014) [14] have cited the work of Lengsfeld et al (2000) who have stated that a lordotic posture of the lumbar spine should be maintained during sitting, but prolonged sitting and increased lumbar lordosis is generally accepted as a high-risk factor in low back pain. The increase in lordosis may be attributed to an alteration in the intervertebral discs and a loss in the posterior vertebral body height of lumbar spine.

Hegazy et al (2014), [14] in their retrospective study on normal MRI's have found that the Anterior Height (AH) of lumbar vertebral bodies in both sexes increased in a craniocaudal direction. But in our study same results are found in males, while in females it increased upto L2 only. In their study regarding the Posterior Height (PH), there was an increase in its mean in males from L1 (m: 26.30 mm) to L2 (m: 27.13 mm) followed by a slight and gradual decrease to L5 (m: 24.09 mm). The PH in females showed the same trend of the male PH, but the change in the values occurred at L3 instead of L2. In our study, PH increased upto L3 in males and upto L2 in females. In their study, these dimensions of male vertebrae were greater than those of females with variable values. We have also got the same results. Alam et al (2014) [8] have also concluded that all the dimensions of lumbar vertebrae were greater in males than females, in that the anterior body height was found to be significantly greater in males in L5 vertebra (p < 0.05) and the posterior heights of L1, L2 and L3 were significantly greater in males (p < 0.05). [8]

Blake et al (1997) have stated that vertebral fractures are usually diagnosed by visual interpretation of lateral radiographs of the lumbar and thoracic spine. Vertebral morphometry based on measurements of the heights of the vertebral bodies is a useful adjunct to the visual reading of radiographs. Mavrych et al (2014) [9] have stated that information regarding the precise dimensions of the lumbar vertebral bodies is essential for spinal surgery and instrumentation. Gocmen-Mas et al (2010) [10] has referred to the work of Chou et al (2008) and said that measurements of size and volumetric definition for bodies of lumbar vertebrae are important for preventing complications after anterior approach in spinal surgeries.

CONCLUSION

Our study suggests similarity in trend of lumbar vertebral body heights from both direct and imaging measurements. We have found non-significant association between anterior and posterior heights of bodies of all the lumbar vertebrae and in various age groups. In Age Group-I, significant association was found between gender and posterior heights of all, and anterior heights of 4th and 5th lumbar vertebral bodies. In Age Group-III, significant association was found between gender and posterior height of 1st and anterior height of 5th lumbar vertebral bodies.

The present study thus emphasises the importance of preoperative conventional radiography of each patient in planning a surgical procedure, selecting the appropriate size of the instruments, designing implants and treatment of low back pain. Moreover, these normal figures could also be of forensic importance because of the observed regional variations.

ACKNOWLEDGEMENT

We would like to thank Dr. Harshal Gupta, Associate Professor in PSM department for helping in statistical work.

REFERENCES

[1] Evolution doesn't explain erect human vertebral column. http://evolutionwiki.org/wiki/Evolution_doesn't_expl ain_erect_human_vertebral_column.

[2] Leone A, Guglielmi G, Cassar-Pullicino VN, et al. Lumbar intervertebral instability: a review. Radiology 2007;245(1):62-77.

[3] Briggs AM, Greig AM, Wark JD, et al. A review of anatomical and mechanical factors affecting vertebral body integrity. Int J Med Sci 2004;1(3):170-80.

[4] Kowalski RJ, Ferrara LA, Benzel EC. Biomechanics of the Spine. Neurosurg Q 2005;15(1):42-59.

[5] Levangie PK, Norkin CC. Joint structure and function a comprehensive analysis. 4th edn. Jaypee Brothers 2006: p. 144-76, 490.

[6] Standring S, Healy JC, Johnson D, et al. Grays Anatomy: the anatomical basis of clinical practice. 40th edn. London: Churchill Livingstone 2008: p. 535, 714-44.

[7] Azu OO, Komolafe OA, Ofusori DA, et al. Morphometric study of lumbar vertebrae in adult South African subjects. Int J Morphol 2016;34(4):1345-51.

[8] Alam MM, Waqas M, Shallwani H, et al. Lumbar morphometry: a study of lumbar vertebrae from Pakistani population using computed tomography scans. Asian Spine J 2014;8(4) :421-6.

[9] Mavrych V, Bolgova O, Ganguly P, et al. Age-related changes of lumbar vertebral body morphometry. Austin J Anat 2014;1(3):1014.

[10] Gocmen-Mas N, Karabekir H, Ertekin T, et al. Evaluation of lumbar vertebral body and disc: a stereological morphometric study. Int J Morphol 2010;28(3):841-7.

[11] Ramadan N, Abd El-Salam MH, Hanon AF, et al. Identification of sex and age for Egyptians using computed tomography of the first lumbar vertebra. Egyptian Journal of Forensic Sciences 2017;7:22.

[12] Atta-Alla el SS, Saab IM, EI Shishtawy M, et al. Morphometric study of the lumbosacral spine and some of its related angles in Lebanese adult females. Ital J Anat Embryol 2014;119(2):92-105.

[13] Abuzayed B, Tutunculer B, Kucukyuruk B, et al. Anatomic basis of anterior and posterior instrumentation of the spine: morphometric study. Surg Radiol Anat 2010;32(1):75-85.

[14] Hegazy AA, Hegazy RA. Midsagittal anatomy of lumbar lordosis in adult Egyptians: MRI study. Article ID 370852, Anatomy Research International 2014;2014: p. 12. http://dx.doi.org/10.1155/2014/370852

Sonali Agichani (1), S. D. Joshi (2), S. S. Joshi (3)

(1) Assistant Professor, Department of Anatomy, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India.

(2) Director/Professor, Department of Anatomy, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India.

(3) Director/Professor, Department of Anatomy, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India.

'Financial or Other Competing Interest': None.

Submission 02-08-2018, Peer Review 31-08-2018, Acceptance 06-09-2018, Published 17-09-2018.

Corresponding Author: Dr. Sonali Agichani, #183, Kalani Nagar, Airport Road, Indore, Madhya Pradesh, India.

E-mail: drsonaliagichani@gmail.com

DOI: 10.14260/jem ds/2018/924

Caption: Figure 1. Median Section of Cadaver showing Anterior (Red) and Posterior (Yellow) Heights measured on Lumbar Vertebral Body

Caption: Figure 2. Lateral View Digital Radiograph of Lumbar Spine showing Anterior (Red) and Posterior (Yellow) Heights measured on Lumbar Vertebral Body
Table-1: Average Anterior and Posterior Heights of Bodies of Lumbar
Vertebrae in Median Sections of Cadavers

V .no   Anterior ht(cms)   Posterior ht(cms)

L1      2.1551             2.3799
L2      2.2685             2.4665
L3      2.3809             2.4018
L4      2.2555             2.3005
L5      2.3488             2.1288

Table 2. V. No- Number of Vertebra; L- Lumbar; 40 Subjects in each age
group; Group I: 21-30 Years, Group II: 31-40 Years, Group III: 41-50
Years

                    Anterior height

V.      Age         Mean     S.D. F   P
no      grp         (cms)

LI      I           2.7925   .25155   1.510 0.225
        II          2.8475   .26793
        III         2 7500   .23425
Total         120   2.7967   .25269
L2      I           2.9400   .27344   2.021 0.137
        II          2.9950   .28280
        III         2.8775   .22474
Total         120   2.9375   .26380
L3      I           2.9425   .21109   1.393 0.252
        II          2.9800   .25237
        III         2.8850   .29833
Total         120   2.9358   .25726
L4      I           2.9600   .30785   2.929 0.057
        II          2.9725   .29088
        III         2.8275   .29176
Total         120   2.9200   .30170
L5      I           2.9800   .32042   0.885 0.415
        II          2.9600   .37744
        III         2.8725   .44491
Total         120   2.9375   .38393

              Posterior height

V.      Age   Mean     S.D. F           P
no      grp   (cms)

LI      I     2.9875   .23225   0.294   0746
        II    3.0075   .24114
        III   2.9650   .26942
Total         2.9867   .24664
L2      I     3.0700   .22781   0.319   0.728
        II    3.0900   .26775
        III   3.0450   .26013
Total         3.0683   .25104
L3      I     3.0700   .29974   2.240   0.111
        II    3.1325   .24326
        III   3.0075   .24535
Total         3.0700   .26682
L4      I     2 8850   .30429   1.038   0.357
        II    2.9575   .26495
        III   2.8775   .25063
Total         2.9067   .27432
L5      I     2.7150   .31748   2.088   0.129
        II    2.7875   .27567
        III   2.6575   25908
Total         2.7200   .28773

Table 3. V. No- Number of Vertebra; L- Lumbar; 20 Males
and 20 Females, in each age group. Group 1:21-30 Years,
Group II: 31-40 Years, Group III: 41-50 Years

                                 Anterior height

Age   V.no   Sex       Mean      S.D      I test   P value
grp                    (cm)               value

I     L1     Males     2.8250    .27314   0.814    0.421
             Females   2.7600    .23033
      1.2    Males     2.9900    .26735   1.162    0.253
             Females   2.8900    .27701
      13     Males     3.0050    .16694   1.938    0.060
             Females   2 88(H)   .23530
      L4     Males     3.1000    .25547   3.199    0.003
             Females   2.8200    J29665
      L5     Males     3.1250    .28814   3.179    0.003
             Females   2.8350    .28887
II    L1     Males     2.8950    .27999   1.125    0.268
             Females   2.8000    .25340
      1.2    Males     3.0400    .27028   1.007    0.321
             Females   2.9500    .29469
      L3     Males     3.0450    .27237   1.666    0.104
             Females   2.9150    .21831
      L4     Males     3.0300    .28488   1.260    0.215
             Females   2.9150    -29249
      1.5    Males     3.0700    33419    1.904    0.064
             Females   2.8500    39403
III   L1     Males     2.7900    .21981   1.082    0.286
             Females   2.7100    .24688
      L2     Males     2.9150    .19270   1.057    0297
             Females   2.8400    .25215
      L3     Males     2.9550    .26848   1.508    0.L40
             Females   2.8150    31669
      1A     Males     2.9100    .26137   1.842    0.073
             Females   2.7450    30345
      13     Males     3.0500    .48395   2.723    0.010
             Females   2.6950    .32521

                                 Posterior height

Age   V.no   Sex       Mean      S.D.     I test   P value
grp                    (cm)               value

I     L1     Males     3.0650    .23681   2.213    0.033
             Females   2.9100    .20494
      1.2    Males     3.1750    .19433   3.254    0.002
             Females   2.9650    .21343
      13     Males     3.2100    .29540   3310     0.002
             Females   2.9300    .23642
      L4     Males     3.0500    .27048   4.051    0.000
             Females   2.7200    .24409
      L5     Males     2.8950    .21879   4323     0.000
             Females   2.5350    .30136
II    L1     Males     3.0350    .26808   0.717    0.478
             Females   2.9800    .21423
      1.2    Males     3.1250    .28261   0.823    0.415
             Females   3.0550    .25438
      L3     Males     3.1750    .23814   1.108    0.275
             Females   3.0900    .24688
      L4     Males     3.0150    .28521   1.389    0.173
             Females   2.9000    .23620
      1.5    Males     2.8250    .29357   0.857    0397
             Females   2.7500    .25854
III   L1     Males     3.0550    .25021   2.216    0.033
             Females   2.8750    .26333
      L2     Males     3.1000    .25955   1351     0.185
             Females   2.9900    .25526
      L3     Males     3.0550    .24382   1.233    0.225
             Females   2.9600    .24366
      1A     Males     2.9050    .20641   0.689    0.495
             Females   2.8500    .29110
      13     Males     2.7150    .28149   1.422    0.163
             Females   2.6000    .22711
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Title Annotation:Original Research Article
Author:Agichani, Sonali; Joshi, S.D.; Joshi, S.S.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Sep 17, 2018
Words:4046
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