The National Ribat University
Faculty of Graduate Studies And Scientific Research
Evaluation of The Lumbar Canal Dimensions at L4
Level Using MRI Images
A Thesis Submitted For Partial Fulfillment Required For The Degree Of
MS.c In Clinical and Human Anatomy
By : Ahmed Bushra MohamedAli Elgali
Supervisor:
Dr. Yasser Seddeg
2016
I
بسم اهلل الرحمن الرحيم
قال تعالى :
ِ ل ك بحان وا س ال " ق ِ ل م ا إ ن ل م ل ا ن ت لم ا
يم "ك الح ليم الع ت أن إنك
صدق هللا العظيم
(32سورة البقرة اآلية )
II
DEDICATION
To my beloved family ,
anything good that has come to my life has been because of your
guidance and love .
III
ACKNOWLEDGEMENT
I want to express my sincere thanks and deep gratitude to my faithful
supervisor: Dr Yasir Siddig, for his guidance through this thesis.
My deep thanks also extended to Dr. Mohamed Elfatih , my best
freind , for his great help he offers to me in selecting and documenting all
cases of study.
My deep thanks also extended to Mr. Mohamed Ahmed Abdalla the
head radiology technician of Royal Care Centre, who helped me over the
period I have expended there to collect the cases of study.
I would also like to thank my friends, who encouraged me to start and
complete this thesis.
Thanks to the support of my parents without which I would not have had
the wonderful opportunity to write this thesis.
My prayers for all of them.
IV
List of contents
PAGE NO TOPICS
I Holy Quran verse
II Dedication
III Acknowledgment
IV List of contents
V List of contents
VI List of tables
VII List of figures
VIII Abbreviation
IX Abstract in arabic
X Abstract
11 CHAPTER-I (Introduction and Objectives )
1 1-1Introduction
2 1.2. Objectives
2 1.2.1. General objective
2 1.2.2. Specific objectives
3 CHAPTER-II (Literature Review)
3 2-1 vertebral column
4 2. 2 lumbar spine
9 2.3 Structure of L4 vertebra
10 2. 4 lumbar vertebral canal
13 2.5 L4 canal measurment
18 CHAPTER-III(Materials and Methods)
18 3.1 study design
18 3.2 sample size
V
18 3.3. Inclusion criteria
18 3.4. Exclusion criteria
18 3.5. Methodolgy
20 CHAPTER-IV(Results)
26 Chapter -V(Discussion)
29 Chapter VI (Conclusion and Recommendations )
29 6.1 conclusion
29 6.2 recommendation
30 Chapter VII (References)
Appendices
VI
List of tables
Page Tables No.
20 Table (4.1): Study group gender distribution 1
21 Table (4.2): Study age group distribution. 2
22 Table (4.3): Study of L4 canal dimensions. 3
24 Table (4.4) Influence of gender on L4 canal dimensions 4
25 Table (4.5) age grouping VS AP & TR diameter 5
28
Table (5.1) comparison between AP & TR diameter of L4
canal of present study with diameter reported in other
studies
6
VII
List of figures
Page Figures No
4 (Fig. 2.1) lower spine , anterior view 1
6 (Fig. 2.2): lumbar vertebrae 2
7 (Fig. 2.3): drawing of 2 lumbar vertebrae
segment 3
9 (Fig. 2.4) joints between 2 lumbar vertebrae 4
12 (Fig. 2.5) cauda equina 5
13 (Fig.2.6) manual Vernier Caliper. 6
14 (Fig 2.7) digital Vernier Caliper 7
14 (Fig 2.8) electronic Caliper for computerized
skull images 8
21 (Fig 4.1). Study age group distribution 9
22 (Fig 4.2) L4 canal AP diameter VS gender 10
23 (Fig 11) L4 canal TR diameter VS gender 11
VIII
Abbreviation
Computerize tomography CT
Magnetic resonant image MRI
Transverse TR
Stander deviation SD
Significance Sig
Anteroposterior AP
Intervertebral IV
IX
مستخلص البحث
خلفية وأهداف البحث :
الرابعة ة القطنيةيرويال كير بالخرطوم ، وتهدف إلى قياس القناة الفقار تمت هذه الدراسة في مركز
وسط المواطنين السودانيين .
منهجية البحث :
سنة 75إلى 20أنثى ( تتراوح أعمارهم من 26ذكر و 24حالة ) 50كانت الدراسة وصفية لعدد
ي مقاطع افقية ورأسية مختلفة " ف1.5خضعوا لتصوير الرنين المغنطيسي بجهاز "توشيبا فنتاج
.ثم تم إيجاد العالقة بين المتغيرات (اس بي اس اس)ثم خضعوا للتحليل اإلحصائي ببرنامج ,
النتائج :
وجدت الدراسة اختالف احصائي ملموس بحيث يتغير البعد الطولي للقناة الفقارية القطنية الرابعة
اختالف احصائي ملموس في البعد الطولي والعرضي للقناة باختالف الفئات العمرية . ولم تجد
الفقارية القطنية الرابعة باختالف الجنس .
ملمتر( ، ومتوسط البعد العرضي 15.57متوسط البعد الطولي للقناة الفقارية القطنية الرابعة هو )
ملمتر ( . 22.89للقناة الفقارية القطنية الرابعة هو )
الخالصة :
غنطيسي وسيلة فعالة في قياس أبعاد القناة الشوكية .الرنين الم
X
ABSTRACT
Background and Objective: The study was carried out at Royal Care
centre- khartoum which aimed to establish the measurements of lumbar
vertebral canal at L4 level among Sudanese people .
Methodology: It was a descriptive study among 50 subjects (24 males and
26 females) aged from 20-75years underwent spine scanning by Toshiba
Vantage 1.5T MRI machine for images in different body plains for the
measurement of L4 vertebral canal. Statistical analysis was performed
using (SPSS) version 16. Correlations between the variables were
performed.
Results: There was significant statistical differences between age groups
and AP diameters of L4 lumbar canal. Although there was no significant
differences between males and females in both AP and TR diameters. The
mean AP diameter was (15.57 mm) and The Mean TR diameter (22.89 mm
) .
Conclusion: MRI is a very useful and effective tool in measuring spinal
canal dimensions.
Chapter I
Introduction and
Objectives
1
1. Introduction and Objectives
1-1 Introduction:
The spinal column is composed of 33 vertebrae arranged as 7 cervical, 12
thoracic, 5 lumbar, 5 fused sacral vertebrae and the 4 fused coccyx. Except
for C1, C2 and the sacrum, coccyx, each vertebra has similar osseous
elements which include the vertebral body, pedicles, articular pillars ,
laminae and transverse process . (1)
Of these, the lumbar, sacral and the coccygeal segments constitute the
lumbosacral spine. The intervertebral (I.V.) foramina are situated
posteriorly between two adjacent vertebral pedicles. The dorsal and ventral
roots mixed together to form nerve trunk which makes its exit through the
I.V. foramen. It is at the level of the foramen by which nerve roots leave
the vertebral canal that they are most commonly compressed. Commonest
causes of such narrowing are fibrosis (hypertrophy) of the ligamentum
flavum, bony proliferation from the margins of the foramen
and posterolateral protrusion or rupture of an I.V. disc. [2]
Ninety percent of lumbar disc extrusions occur at L4‑L5 or L5‑S1, while,
of the remainder, most occur at L3‑L4. The central lesion may cause no
symptoms as the exiting nerve roots remain unaffected. Paracentral lesions
cause symptoms as a result of compression of the exiting nerve root. [3]
Various radiological procedures which are used for the diagnosis have their
own advantages and disadvantages. But, magnetic resonance imaging
(MRI) which is a relatively newer technique, is treated as the gold standard
in this field. Parasagittal images are used to evaluate foraminal stenosis. In
regard to the margins of the foramen, the disc and vertebral body lie
anteriorly, the pedicles superiorly and inferiorly, and the facet joints
2
posteriorly. On axial imaging, the margins of the spinal canal consist of the
vertebral body anteriorly, the pedicles laterally and the lamina posteriorly
[3].
In MRI scan, spinal lignments, disc height and hydration, vertebral body
configuration, spinal canal size, spinal cord and nerve root compression
could be studied.
Lower back pain (Sciatica) is a common condition with a large economic
impact both to the individual and to the industry. It has been estimated that
sciatica strikes approximately 2–3% of the population and has a prevalence
of 4.8% in men and 2.5% in women elder than 35 years of age. [3]
1.2. Objectives:
1.2.1. General objective:
Evaluation of lumbar canal dimention at L4 level using MRI images .
1.2.2. Specific objectives:
1- To correlate between gender and lumbar canal dimensions at L4.
2- To correlate between age and lumbar canal dimensions at L4.
Chapter II
Literature Review
3
2. Literature Review
2-1 Vertebral column :
The vertebral column is a curved linkage of individual bones or
vertebrae. A continuous series of vertebral foramina runs through the
articulated vertebrae posterior to their bodies, and collectively
constitutes the vertebral canal, which transmits and protects the spinal
cord and nerve roots, their coverings and vasculature. A series of paired
lateral intervertebral foramina transmit the spinal nerves and their
associated vessels between adjacent vertebrae. The linkages between the
vertebrae include cartilaginous interbody joints and paired synovial facet
(zygapophyseal) joints, together with a complex of ligaments and
overlying muscles and fasciae.
The adult vertebral column usually consists of 33 vertebral segments.
Each presacral segment (except the first two cervical) is separated from
its neighbour by a fibrocartilaginous intervertebral disc.
The functions of the column are to support the trunk, to protect the spinal
cord and nerves, and to provide attachments for muscles. It is also an
important site of haemopoiesis throughout life. Its total length in males is
c.70 cm and in females c.60 cm. The intervertebral discs contribute about
a quarter of this length in young adults, though there is some diurnal
variation in this contribution. Approximately 8% of overall body length is
accounted for by the cervical spine, 20% by the thoracic, 12% by the
lumbar and 8% by the sacrococcygeal regions. Although the usual number
of vertebrae is 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4 coccygeal,
this total is subject to frequent variability, and there have been reports of
variation between 32 and 35 bones.
4
The vertebral canal extends from the foramen magnum to the sacral
hiatus, and follows the vertebral curves. In the cervical and lumbar
regions, which exhibit free mobility, it is large and triangular, but in the
thoracic region, where movement is less, it is small and circular.
These differences are matched by variations in the diameter of the spinal
cord and its enlargements. In the lumbar region, the vertebral canal
decreases gradually in size between L1 and L5, with a greater relative
width in the female. (4)
2. 2 lumbar spine:
The lumbar spine consists of 5 moveable vertebrae numbered L1-L5. The
complex anatomy of the lumbar spine is a remarkable combination of
these strong vertebrae, multiple bony elements linked by joint capsules,
and flexible ligaments/tendons, large muscles, and highly sensitive
nerves. It also has a complicated innervation and vascular supply.
The lumbar spine is designed to be incredibly strong, protecting the highly
sensitive spinal cord and spinal nerve roots. At the same time, it is highly
flexible, providing for mobility in many different planes including flexion,
extension, side bending, and rotation.
Fig (2.1) Lower spine, anterior view. Modified from
http://www.emdeicine.medscape.com
5
The lumbar vertebrae, numbered L1-L5, have a vertical height that is less
than their horizontal diameter. They are composed of the following parts:
The vertebral body, designed to bear weight .The vertebral (neural) arch,
designed to protect the neural elements .The bony processes (spinous
and transverse), which function to increase the efficiency of muscle
action.
The lumbar vertebral bodies are distinguished from the thoracic bodies
by the absence of rib facets. The lumbar vertebral bodies (vertebrae) are
the heaviest components, connected together by the intervertebral discs.
The size of the vertebral body increases from L1 to L5, indicative of the
increasing loads that each lower lumbar vertebra absorbs.
Of note, the L5 vertebra has the heaviest body, smallest spinous process,
and thickest transverse process. The intervertebral discal surface of an
adult vertebra contains a ring of cortical bone peripherally termed the
epiphysial ring. This ring acts as a growth zone in the young while
anchoring the attachment of the annular fibers in adults. A hyaline
cartilage plate lies within the confines of this epiphysial ring.
Each vertebral arch is composed of 2 pedicles, 2 laminae, and 7 different
bony processes (1 spinous, 4 articular, 2 transverse), joined together by
facet joints and ligaments. (4) (5)
6
fig (2.2 ) Lumbar vertebrae are characterized by massive body
Modified from http://www.emdeicine.medscape.com
The pedicle, strong and directed posteriorly, joins the arch to the
posterolateral body. It is anchored to the cephalad portion of the body
and function as a protective cover for the cauda equina contents. The
concavities in the cephalad and caudal surfaces of the pedicle are termed
vertebral notches. Beneath each lumbar vertebra, a pair of intervertebral
(neural) foramina with the same number designations can be found, such
that the L1 neural foramina are located just below the L1 vertebra. Each
foramen is bounded superiorly and inferiorly by the pedicle, anteriorly by
the intervertebral disc and vertebral body, and posteriorly by facet joints.
The same numbered spinal nerve root, recurrent meningeal nerves, and
radicular blood vessels pass through each foramen. Five lumbar spinal
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7
nerve roots are found on each side. The broad and strong laminae are the
plates that extend posteromedially from the pedicle. The oblong shaped
spinous processes are directed posteriorly from the union of the laminae.
The 2 superior (directed posteromedially) and inferior (directed
anterolaterally) articular processes, labeled SAP and IAP, respectively,
extend cranially and caudally from the point where the pedicles and
laminae join. The facet or zygapophyseal joints are in a parasagittal plane.
When viewed in an oblique projection, the outline of the facets and the
pars interarticularis appear like the neck of a Scottie dog . (5)
Fig (2.3 )Drawing of 2 lumbar segments viewed from an oblique angle. The
outline of the facets and the pars interarticularis has the appearance of
the "neck" of a Scottie dog.
Modified from http://www.emdeicine.medscape.com
The lumbar spine has an anterior, middle, and posterior column that is
pertinent for lumbar spine fractures . The mobility of the vertebral column
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8
is provided by the symphyseal joints between the vertebral bodies,
formed by a layer of hyaline cartilage on each vertebral body and an
intervertebral disc between the layers.
The synovial joints between the superior and inferior articular processes
on adjacent vertebrae are termed the facet joints (also known as
zygapophysial joints or Z-joints ). They permit simple gliding movements.
The movement of the lumbar spine is largely confined to flexion and
extension with a minor degree of rotation . The region between the
superior articular process and the lamina is the pars interarticularis. A
spondylolysis occurs if ossification of the pars interarticularis fails to
occur. (5)
9
Fig (2.4 ) The 3-joint complex is formed between 2 lumbar vertebrae. Joint
1: Disc between 2 vertebral bodies; Joint 2: Left facet (zygapophyseal)
joint; Joint 3: Right facet (zygapophyseal) joint.
Modified from http://www.emdeicine.medscape.com
2.3 Structure of L4 vertebra:
The L4 vertebra is the penultimate of the five (5) lumbar vertebrae,
located just above the fixed vertebrae of the sacrum and thus one of the
last of the true vertebrae or movable vertebrae in the spinal column.
Like the other lumbar vertebrae, the L4 is very large in both the cylindrical
centrum (vertebral body) and the vertebral arch in order to support the
weight of the body and handle the vertical compression of the spine
above it.
This puts a great deal of pressure on the cartilaginous intervertebral discs
between the relatively flat surfaces of the centrum that form the articular
facets of the joints between superjacent and subjacent vertebrae (the L3
and L5, respectively).
The nearly horizontal and rectangular spinous process is likewise
substantial, in order to counteract the force of strong muscles in the lower
back that attach to it. As for the rest of the vertebral arch, it includes short,
strong pedicles with superior and inferior notching; thick laminae; and
thin, long transverse processes all surrounding a relatively large,
triangular vertebral process through which the spinal cord passes safely.
Between each transverse process and pedicle there is a superior articular
process and an inferior articular process, each with a facet that articulates
with the complementary facet of the vertebra above and below the L4,
respectively. The L4 vertebra's transverse processes are noteworthy for
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10
lacking transverse foramina, as with the other lumbar vertebrae. Also
consistent with the lumbar region of the spine, the centrum lacks external
articular facets. (6)(5)(4)(7)
2. 4 Lumbar vertebral canal :
The tubular vertebral canal contains the spinal cord, its meninges, spinal
nerve roots, and blood vessels supplying the cord, meninges, vertebrae,
joints, muscles, and ligaments. Both potential and real spaces intervene
between the spinal cord, meninges, and osseoligamentous canal walls.
The canal is enclosed within its column and formed by the juxtaposition
of the vertebral foramen, lined up with one another in series. The
vertebral bodies and discs make up the anterior wall (with the PLL draped
over it), whereas the laminae and ligamentum flavum border the canal
posteriorly. Laterally, spinal nerves and vessels travel through the
intervertebral foramen.
The meninges consist of 3 layers: the pia, arachnoid, and dura mater.
Together, they enhance the protection of the spinal cord and roots. The
dura is the most superficial but resilient layer. The pia and arachnoid,
together termed the leptomeninges, are frail. The spinal cord, roots, and
nerve rootlets are closely invested by the pia. The dura and arachnoid
together form a loose sheath (termed dural/thecal sac) around these
structures, separated from the canal walls by the epidural space.
The dura continues caudally as a fibrous thread named the filum
terminale externum or coccygeal ligament, which blends with the PLL
over the coccyx
11
The arachnoid mater lines the entire dural sac and extends into the dural
sleeves. It also sends trabeculae across the subarachnoid space to the pia,
facilitating CSF mixing. Along the posterior midline, the trabeculae form a
well-defined subarachnoid septum. Inferiorly, it lines the dural sac within
the sacral canal and ends on termination of the sac at the S2 vertebral
level.
The pia forms a separate sheath for each nerve rootlet and root as far
laterally as the foramen, blending with the epineurium. Caudally, the pia
continues as the thin filum terminale internum. After reaching the lower
end of the dural sac, the filum becomes enclosed within the filum
terminale externum and continues to the coccyx.
The spinal subarachnoid space is spacious in the lumbar spine, and below
the level of L2 it is termed the lumbar cistern. Its CSF content (20-35 mL)
is only a fraction of the total CSF volume (120-150 mL). The lower third of
the arachnoid sac contains only the filum terminale internum and the
cauda equina, which contains lumbar, sacral, and coccygeal nerve roots
that hang like a horse’s tail form the lower part of the spinal cord (conus
medullaris) as they leave the vertebral canal below the lower third of the
arachnoid sac .
The spinal cord normally terminates as the conus medullaris within the
lumbar spinal canal at the lower margin of the L2 vertebra, although
variability of the most caudal extension exists .
12
Fig (2.5 ) Illustration demonstrating the relevant anatomy of the cauda
equina region. Modified from http://www.emdeicine.medscape.com
2.5 L4 canal measurements:
The measurement of L4 lumbar canal dimensions are carried out on dry
vertebra ,plane radiograph, MRI or CT scan images , using manual or
digital Vernier Caliper, and electronic Caliper for computerized images to
measure the maximum AP and transverse diameter .
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13
Fig (2.6 ) manual Vernier Caliper. Modified from
http://faculty.tcc.fl.edu/scma/carrj/Phy2048L
Fig (2.7 ) digital Vernier Caliper. Modified from
http://www.myrcmodel.com
http://faculty.tcc.fl.edu/scma/carrj/Phy2048Lhttp://www.myrcmodel.com/
14
Fig(2.8) electronic Caliper for computerized images. From
http://www.ijoonline.com/articles/2011/45/1/images/indianJOrththo_2
011_45_1_63_73661_f5.jpg
There was many previous studies of deferent countries had been
published in the measurements of L4 Lumbar canal dimentions using
different methods.
Pawar (8) from india using MRI states that the mean AP diameter of L4 in
normal population is (12.98 mm ±1.09 SD ) ranges (11.0-15.1 mm) and
mean transverse diameter is (26.45 mm ±2.52 SD) ranges (22.6-32.5 mm)
.
AMONOO-KUOFI (9) from Nigeria using dry vertebra stated that, the
mean AP diameter of L4 in males is (15.6 mm ±2.0 SD ) the ranges (11.6-
19.6 mm ) and the mean in females is( 14.1 mm ±1.3 SD) the ranges (11.5
-16.7 mm).
Tanveer (10) from india using MRI states that, the mean AP diameter of
L4 canal in clinically asymptomatic non-stenosed cases is ( 14.64 mm ±
http://www.ijoonline.com/articles/2011/45/1/images/indianJOrththo_2011_45_1_63_73661_f5.jpghttp://www.ijoonline.com/articles/2011/45/1/images/indianJOrththo_2011_45_1_63_73661_f5.jpg
15
0.35 SD) . and the transverse diameter in non-stenosed asymptomatic
patients of L4 canal is (24.5 ± mm 0.47 SD).
Mukesh (11) from Nepal using CT measurements reported that, the mean
AP diameter of L4 canal was ( 14.87 mm ± 2.08 SD) and the mean
transverse diameter was (25.08 mm ± 3.60 SD).
Midia ( 12) from Iran using CT images stated that , the mean AP diameter
of L4 is ( 14 mm ±2.7 SD ) and the mean TR diameter was ( 23mm ±
2.1 SD) .
El-Rakhawy ( 13) from Egypt using both dry bone and plain radiograph
revealed that , in radiographic studies the mean AP diameter in males was
(11.7 mm) the range ( 9.4-14 mm) and (11 mm ) the range ( 8.9-13.2 mm)
in females .while the mean TR diameter was (25.4 mm) the range (19.8 –
31.0 mm) in males . In females it was ( 24.7 mm) range ( 19.5- 31.0 mm) .
regarding the dry bones study they stated that the TR diameter was ( 23.5
mm)
Elhassan (14) from Sudan also using MRI images states that , the mean AP
diameter of L4 canal is (16.2 mm ±2.5 SD) in males and (17.0 mm ± 2.9SD
) in females .
Mashrabi (15) from Iran using CT measurements revealed that the mean AP
diameter of L4 was ( 14 mm ± 2.7 SD ) and the mean transverse diameter
was (23 mm ± 2.1 SD).
Kumar (16) from India using AP and lateral radiograph measured the canal
via Eisenstein's Method and Jones and Thompson's Method they reported
that , mean AP diameter is ( 14 mm ±1.3 SD) the range (11-17 mm) and
mean TR diameter is (25 mm ± 2.61 SD) the range (20-30mm).
16
Dhungana (17) from Nepal using plain radiograph with the help of
electronic calipers. reported that , the mean L4 canal transverse diameter is
(27.68 mm ± 3.1 SD) and mean AP diameter is (10.27 mm ± 1.7 SD)
Cheung (18) from Japan using MRI stated that , the mean AP diameter of
L4 is (17.0 mm ±4.01 SD ) in T1 and (16.5 mm ±3.70 SD) in T2 . They also
stated that the transverse diameter of L4 (25.8 mm ±2.33 SD) in T1 and
(25.1 mm ±2.24 SD)in T2.
Orhan (19) from Turkey measured the transverse diameter of L4 using plain
anterioposterior radiograph stated that, the mean transverse diameter in
male is (29.91 mm ±3.08 SD) and female (28.67 mm ±2.66 SD) the ranges
in male (29.29 – 30.52 mm) and the ranges in female (28.14 – 29. 20 mm).
Vinay (20) from india using plain AP radiograph states that , the mean
transverse diameter of L4 canal is ( 28.47 mm ±2.98 SD ) in males and (
26.74 mm ±3.24 SD) in females.
Sethi (21) from India using plane radiograph stated that , the mean
transverse diameter of L4 canal in males is (28.16 mm ±5.85 SD) and in
females was (30.63 mm ± 4.36 SD)
Shalini (22) from Khanpur Kalan,sonepat , Haryana measuring the
transverse diameter of L4 reported that was (27.15 mm ± 3.9 SD ) in males
and (25.71 mm ±2.4 SD) in females .
17
Chapter III
Material and
Methods
18
3. Material and methods
3.1. Study design:
The study was a descriptive one using different axial sections of lumbar
spine MRI images.
3.2. Sample size :
This study was conducted on (50) subjects at Royal Care medical Centre -
Khartoum state – Sudan, from July 2015 till September 2015.
3.3. Inclusion criteria:
subjects of well-established diagnosis of normal L4 vertebra were
selected for the study from different age, sex and profession.
3.4. Exclusion criteria :
Any subject of well diagnosed with L4 lesions, masses or congenital
anomalies was excluded from this study.
3.5. Methodolgy:
The technologist performed The MRI of the lumbar spine. The machine
used in this study was Toshiba Excelart Vantage 1.5T MRI machine.
The images was displayed on PAXERAMED DICOM Viewer and software
version 7.0.9 used for reading and measuring lumbar canal dimensions at
L4.
An individualized approach to evaluate the L4 lumbar spine dimensions
was taken using axial sections. The maximum anteroposterior and
transverse diameters of the lumbar spine were measured. Electronic
calipers is used in the measurement.
19
All data was collected from patient's files and archived MRI images with
the aid of data collection sheet designed by the researcher especially for
the purpose of research.
Statistical analysis was performed using the Statistical Package for the
Social Sciences (SPSS) version 16 (SPSS, Chicago, Illinois, USA) and
Microsoft excel 2013. Data was expressed as frequencies and as a
proportion for continuous and categorical variables. The maximum,
minimum and mean calibers were calculated. Correlations between the
variables were performed using ANOVA analysis, Means and Chi-Square
Tests correlation. Probabilities of p
Chapter IV
Results
20
4. Results
As shown in table (4.1), the total number of subject underwent study
was 50 cases, 26(52%) are male and 24(48%) are female. The age of the
study group ranging from 20 to 75 years old. Table( 4.2), divided to four
groups. The Frequency of group1 (20-35) is six patients (32%), group2
(36-50) is twelve patients (32%), group3 (51-65) is eleven patients (32%),
group4 (66-80) is thirteen patients (4%), fig (4.1). The anteroposterior
diameter of the L4 canal measures mean of 15.57 mm (ranging from 18.94
mm to 12.32 mm), and the transverse diameter measures mean of 22.89
mm (ranging from 17.64 mm to 27.91 mm) Table (4.3).
Table (4.1): Study group gender distribution
sex Frequency Percent
female 24 48.0
male 26 52.0
Total 50 100.0
21
Table (4.2): Study age group distribution.
Fig (4.1): Study age group distribution.
Percentage of age group
20-35
36-50
51-65
66-80
Group
age Frequency Percent
G1 20-35 16 32.0
G2 36-50 16 32.0
G3 51-65 16 32.0
G4 66-80 2 4.0
Total 50 100.0
22
Table (4.3): Study of L4 canal dimensions :
Mean Maximum Minimum N
15.57 18.94 12.32 50 AP diameter
22.89 27.91 17.64 50 TR diameter
As shown in Figure (4.1), there is slight difference for male and female in
AP diameter, and it is not significant (p= 0.130). The mean AP of the male
is 15.95 mm ±1.81 SD and the mean AP diameter of the female is 15.16
mm ±1.79 SD. The maximum AP diameter of the male is 18.94 mm, and
the maximum AP diameter of the female is 18.92 mm.
The minimum AP diameter of the male is 12.52 mm, and the minimum AP
diameter of the female is 12.32 mm. Table (4.4)
Fig (4.2): L4 canal AP diameter versus gender
0
2
4
6
8
10
12
14
16
18
20
MeanMaximumMinimum
female
male
23
As shown in Figure (4.3), There is no significant difference in the mean TR
diameter of male and female (p= .812). The mean TR diameter of the male
is 22.78 ±2.87 SD, and the mean TR diameter of the female is 22.92 ± 3.09
SD. The maximum TR diameter of the male is 26.57 mm, and the
maximum TR diameter of the female is 27.91 mm . The minimum TR
diameter of the male is 18.4 mm, and the minimum TR diameter of the
female is 17.64 mm. Table (4.4)
Fig (4.3): L4 canal TR diameter versus gender
0
5
10
15
20
25
30
MeanMaximumMinimum
female
male
24
Table (4) Influence of gender on L4 canal dimensions
Sex AP Transverse
female Mean 15.1654 22.9971
SD 1.79006 3.09394
Minimum 12.32 17.64
Maximum 18.92 27.91
male Mean 15.9515 22.7950
SD 1.81801 2.87958
Minimum 12.52 18.40
Maximum 18.94 26.57
Total Mean 15.5742 22.8920
SD 1.82969 2.95537
Minimum 12.32 17.64
Maximum 18.94 27.91
As shown in table (4.5) there is highly significant difference (p=.001)
in the mean AP diameter of different age groups. The mean AP diameter
in G1 is 16.82mm (ranging from 14.16 mm to 18.94 mm). The mean AP
diameter in G2 is 15.41 mm (ranging from 17.82 to 13.64 mm). The mean
AP diameter in G3 is 14.83 mm (ranging from 12.32 to 18.32 mm). The
mean AP diameter in G4 is 12.72 mm (ranging from 12.52 to 12.92 mm).
There is no significant different (p=.370) in the mean TR diameter of
different age groups. The mean TR diameter in G1 is 22.97 mm (ranging
25
from 18.40 to 26.57 mm). The mean TR diameter in G2 is 23.52 (ranging
from 19.24 to 26.57 mm). The mean TR diameter in G3 is 22.57 mm
(ranging from 17.64 to 27.91 mm). The mean TR diameter in G4 is 19.74
mm (ranging from 19.67 to 19.82 mm).
Table (4.5) Age grouping versus AP and TR diameter of L4 .
Age Transverse AP
20-35 Mean 22.9700 16.8294
Maximum 26.57 18.94
Minimum 18.40 14.16
36-50 Mean 23.5269 15.4156
Maximum 26.57 17.82
Minimum 19.24 13.64
51-65 Mean 22.5725 14.8344
Maximum 27.91 18.32
Minimum 17.64 12.32
66-80 Mean 19.7450 12.7200
Maximum 19.82 12.92
Minimum 19.67 12.52
Total Mean 22.8920 15.5742
Maximum 27.91 18.94
Minimum 17.64 12.32
Chapter V
Discussion
26
5. Discussion
Studying of Lumbar canal anatomy has become important for diagnosis
of several clinical conditions. Many previous studies of the lumbar
vertebral canal were published and reported age, sex, racial and ethnic
differences in the size of the canal (Elrakhawy 2010, Eisenstein S 1977,
hinck 1966) (13)(23) (24) using different techniques such as dry
measurements, plain films, CT and MRI .
MRI has become investigation of choice for lumbar spinal stenosis as it is
non-invasive, with no radiation risks and gives overview of spine along
with its soft-tissue components.
In current study, which included 50 study MRI was used , data was
collected and measured with assistance of an expert radiology technician
and registrar of medical radiology . Then measurement was done in an
axial section at L4 vertebral level because it allows the best view of for
studying the anatomy of vertebrae.
In the present study , when the AP diameter of L4 was evaluated , it found
that there is slightly difference between male and female. The male canal
(15.9 mm) is greater than female (15.1mm). and this is consistent with the
data reported by AMONOO-KUOFI (9) and El-Rakhawy ( 13) . while this
result different from those reported by Elhassan (14) although the last one
was conducted in Sudan, this discrepancy could be explained by ethnic
differences , because our study population are not all Sudanese .
Comparing the TR diameter of L4 in this study with other studies there is
no significant differences between male(22.7) and female (22.9) and the
27
mean TR diameter was (22.8). This result is not similar of those reported
by El-Rakhawy ( 13) and other authors (20) (21) (22) This variation may be due
to taking different modalities of measurement or using incorrect
methods for detecting the accurate TR diameter .
When AP diameter is evaluated according to the groups of age , this study
found that there is significant reduction in AP diameter with increasing
age. This is a common fact in clinical practice that lumber canal stenosis is
closely related to pathological changes that occur with age especially over
35 years . (3)
Table (5.1) below shows comparison between AP and TR diameter of L4
canal of the present study with diameters reported in the previous
studies.
Table (5.1) comparison between AP and TR diameter of L4 canal of the
present study with diameters reported in the previous studies.
28
Mean TR
diameter
Mean AP
diameter
Method Country Researchers
22.89 15.57 MRI Sudan Present study
26.45 12.98 MRI India Pawar (8)
- M: 15.6
F: 14.1
Dry vertebra Nigeria AMONOO-KUOFI (9)
24.5 14.64 MRI India Tanveer (10)
25.08 14.87 CT Nepal Mallik (11)
23 14 CT Iran Miabi ( 12)
M: 25.4
F: 24.7
M : 11.7
F : 11
Dry bone +
radiograph
Egypt El-Rakhawy( 13)
- M:16.2
F: 17
MRI Sudan Elhassan (14)
25 14 Radiograph India Kumar (16)
Chapter VI
Conclusion
and
Recommendations
29
6. Conclusion and recommendations
6.1. Conclusion :
There was significant statistical difference between age groups and
AP diameter of L4 lumbar canal .
There was no significant statistical difference between both sexes in
TR and AP daimeter of L4 lumbar canal.
6.2. Recommendations :
MRI is a very useful and effective tool in the evaluation of the lumbar
canal dimensions in the life cases.
For more accuracy, New studies are needed including large size
sample from different ethnic groups.
Chapter VII
References
30
7.Referances
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Appendices
Appendices
Data collection sheet:
L4 canal Measurements :