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

http://www.emdeicine.medscape.com/

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

http://www.emdeicine.medscape.com/

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 .

http://www.emdeicine.medscape.com/

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 :