18 May 2023: Clinical Research
A Natural-Position X-Ray for Evaluating Cervical Vertebra Physiology Curvature Before and After Conservative TreatmentZijun Xu1ABCDEF, Yichao Chen 2ABCDEF*, Liping Feng1AG, Qing Lu3ABEG
Med Sci Monit 2023; 29:e939480
BACKGROUND: Abnormal physiological curvature is one of the symptoms of early cervical spondylosis. An X-ray taken with the patient standing in a natural position can best reflect the real cervical vertebra physiological curvature. The purpose of this research was to study the value of natural-position X-ray in evaluating cervical vertebra physiology curvature before and after conservative treatment.
MATERIAL AND METHODS: This study included 135 participants of different ages diagnosed with cervical disease and who received conservative treatment for more than 12 months. The natural- and regular-position X-rays were performed before and after treatment. The positive change of D value in Borden’s measurement and C2~7 Cobb angle should be recognized as an improvement of cervical vertebra physiology curvature.
RESULTS: Before treatment, the C2~7 Cobb angle of the regular-position group was larger than that of natural-position group. After treatment, the C2~7 Cobb angle of the natural-position group was larger than that of the regular-position group, and the D value increased after treatment in both groups. The effective rate of cervical physiological curvature of the natural-position group was higher than that of the regular-position group.
CONCLUSIONS: Natural-position X-ray has greater accuracy in evaluating cervical vertebra physiology curvature before and after conservative treatment compared with regular-position X-ray.
Keywords: Cervical Vertebrae, Patient Positioning, spinal curvatures, Traction
Normal physiology curvature of cervical vertebra is an important factor to maintain effective motor function, and abnormal physiological curvature is one of the symptoms of early cervical spondylosis . With the rapid development of technology, excessive use of mobile devices has recently been reported to be associated with increases in degenerative changes of the cervical vertebrae . A flexed-neck posture when using hand-held mobile devices, which is also called tech-neck , can increase cervical loading  and lead to cervical malalignment (eg, loss of lordosis or kyphosis). Radiographic diagnosis and measurement, as the basic evidence of cervical vertebra physiological curvature evaluation, is of value in the establishment of cervical physiological rehabilitation methods. Although radiographic measurement data are objective, the methods used by technicians are diverse. Different body position for cervical vertebra X-ray and the technical differences among technicians may present different cervical vertebra physiological curvature, which has been confirmed in our preliminary experiments. However, there are few related reports. According to our research, when patients stand in natural position (neutral lateral position), the muscles and joints of human body are in the best position , and the X-ray taken in this posture can best reflect the real cervical vertebra physiological curvature of the patient. If the X-ray can be taken in the natural-position before and after our treatment and rehabilitation (patent no. ZL 201920952467.4), the difference caused by technicians’ radiography methods could be eliminated. The purpose of this study was to study the accuracy of natural-position X-ray in the evaluation of cervical vertebra physiological curvature before and after conservative treatment, and to determine the optimal scheme of physiological curvature evaluation after conservative treatment of cervical vertebra.
Material and Methods
SELECTION AND GROUPING OF PATIENTS:
From March 2017 to April 2019, we enrolled 135 volunteers (66 males, 69 females, average age 41.5±10.1 years old) diagnosed with abnormal cervical vertebra physiological curvature by clinicians and who received conservative treatment. Before and after treatment, patients underwent cervical spine X-ray examination in natural position and regular position (anteroposterior and lateral position). We excluded patients with cervical trauma, those with severe pain, and those could not cooperate with conservative treatment. The regular position was classified as group A, and the natural position as group B. The subjects were also divided into 3 groups according to age, with 45 patients in each group: the young group (age 25–35 years old), the young and middle-aged group (35–45 years old), and the middle-aged group (45–55 years old).
In regular position, patients stand in front of the camera (Samsung XGEO GC80) frame with their right side close to it. The shoulders are kept as low as possible. The median sagittal plane of the body is parallel to the plate of the camera frame, and the head is tilted back. The neck is placed in the middle line of the irradiation field. The auditory nasal line is parallel to the radiographic panel. The central line is vertically rayed into the camera frame through the side of the thyroid cartilage. The imaging distance is 110 cm.
In natural position, patients stand in front of the camera frame with their right side close to it, and their back close to the vertical plate. The back side of the head, back, buttocks, legs, and both heels are required to cling to the vertical plate surface, which creates the neutral position of natural standing (Figure 1). The neck is placed in the middle line of the irradiation field, and the central line is vertically rayed into the camera frame through the side of the thyroid cartilage. The imaging distance and equipment model are the same with those in regular position.
CONSERVATIVE TREATMENT: TRACTION AND REHABILITATION EXERCISE:
A device (Invention patent No. ZL 201920952467.4) (Figure 2) for cervical vertebra physiological curvature protection in natural position is applied for traction 15 min each time twice a day. According to the patients’ X-ray data, height, and weight, a traction pillow with specific materials and hardness was made for traction to relax the strained cervical muscles. A mean of 12 months traction and rehabilitation was performed. Rehabilitation involved core training and neck stretch training.
To determine the C2–7 Cobb angle, on the lateral X-ray image, we measured the extension lines of the lower edges of C2 and C7 vertebrae, and then drew a vertical line of these 2 lines. Curvature of the cervical vertebra was determined by the acute angle formed by the intersection of the vertical lines. The normal angle is generally 22 ±5°  (Figures 3A, 3B, 4A, 4B).
Borden’s measurement was performed by drawing a straight line from the posterior upper edge of the odontoid process of the axis (the second cervical vertebra) to the posterior lower edge of the C7 vertebral body as line A, then drawing a line along the posterior edge of each vertebral body as line B, and the vertical transverse line at the widest position between lines A and B is line C, which is the depth of the cervical physiological curve. D represents the length of line C. The normal range of the D value is 12±5 mm. IF D is greater than 17 mm, it indicates an excessive curvature; if it is less than 7 mm, it indicates a reduced curvature; if D is negative, it indicates a retroflexion of cervical vertebra  (Figure 3A–3C).
We used SPSS (v19.0, Chicago, IL) software for statistical analyses. The
Before treatment, the C2–7 Cobb angle was −15.2°–49.8° (19.91°±12.9°) for Group A and −16.1°–38.3° (10.98±6.6°) for Group B (
Cervical traction combined with rehabilitation exercises is a common method of conservative treatment of cervical spondylosis. Standardized conservative treatment clearly relieves symptoms of cervical spondylosis, and physiological curvature change is often regarded as an important element of curative effect evaluation . The physiological curvature of the human spine has gradually formed during a long-term evolution process to adapt to the posture of upright walking . Abnormal cervical curvature is an important indicator for early diagnosis of cervical spondylosis. The effective treatment of cervical spondylosis should involve restoration of normal cervical curvature [5,6]. The physiological curvature of the cervical vertebra is closely related to the selection of surgical methods, surgical effect, and postoperative complications of patients with cervical degenerative diseases . Zhao et al  measured the C2–7 Cobb angle of normal Chinese adults, which was 22.4°±8.5°. Gore et al  measured the C2–7 Cobb angle, which was 21.2°±14.6°. The difference in results is due to race, region, and other factors, as well as the inconsistency of imaging position. The imaging skills of technicians and the position of patients may be factors affecting assessment of proper physiological curvature. Lateral X-ray of cervical vertebra is often used as a basic method to measure cervical curvature, and it is also a reference index for clinical evaluation of cervical function, determination of treatment plan, and evaluation of curative effect. In the past, to avoid the overlap between the mandible branch and the upper cervical vertebra, the traditional method of taking lateral radiographs of cervical vertebra was to slightly extend the mandible . In this case, the upper cervical spine (C2–4) would turn backward while the lower half of the cervical spine was not coordinated, which affects measurement of the overall physiological curvature of the cervical vertebra. In addition, some negative K lines (the straight line between C2 and C7 spinal canal midpoint; ossification of posterior longitudinal ligament beyond K line is considered negative) were misjudged as positive (ossification of posterior longitudinal ligament did not exceed K line) under this circumstance . Therefore, patients who were unsuitable for posterior decompression and laminoplasty chose this operation, which may have led to a poor decompression effect. Thus, to increase the accuracy of measurement and evaluation, the measurement of C2–7 Cobb angle was added to Borden’s measurement. To eliminate the effect of differences in technician’s imaging skills, a unified natural position was used, as use of a standardized X-ray position would minimize the effects of differences in technique. At the same time, the natural position requires the patient’s spine to cling to the vertical plate, so that the overall physiological curvature of the cervical vertebra is closer to the actual situation. Our results showed that, after conservative treatment, the C2–7 Cobb angle in the regular-position group increased by 3.29±3.62° and by 1.13±4.05° in the natural-position group. Although the Cobb angle of the regular-position group increased more than that of the natural-position group, the effective rate of the natural-position group was 54.8%, which was much higher than that of the regular-position group (41.5%). This suggests that the cervical curvature increases with the regular jaw-lifting position, which may affect the selection of surgical methods, the evaluation of therapeutic effect, and even lead to the occurrence of complications. The main factor that affects adolescents’ cervical curvature abnormality is the imbalance of cervical muscle strength caused by long-term abnormal posture or acute injury, which destroys the dynamic balance of vertebral stability , and it is mainly manifested as simple cervical curvature abnormality, which may not be accompanied with bone hyperplasia, narrowing of intervertebral space, calcification, vertebral foramen deformation and other changes, and the improvement of cervical curvature is significantly associated with the disappearance of symptoms and signs . However, for middle-aged and elderly patients, cervical curvature abnormality is only one of the manifestations of cervical spondylosis. Cervical curvature abnormality accelerates cervical degenerative changes, which can lead to vertebral osteophyte formation, corresponding intervertebral space narrowing, and uncinate joint hyperplasia. In this study, the effectiveness of conservative treatment of traction and rehabilitation exercises in the young group (25–35 years old), young and middle-aged group (35–45 years old), and middle-aged group (45–55 years old) also supports the above viewpoint. The accuracy of the evaluation method of the physiological curvature curative effect of young patients with cervical spondylosis is vital for correct diagnosis and treatment.
According to our research, patients with cervical spondylosis should be placed in the natural position when undergoing cervical lateral X-rays. With this method, the interference of technicians’ imaging methods can be eliminated and the measurement and evaluation results will be more objective and effective. Although there are few related studies, and our study included a considerable number of subjects, our study has some limitations. Firstly, considering this study is based on modification of body position only, the photography data of multiple types of photographic equipment were not included. Secondly, we did not evaluate curative effects other than physiological curvature. We intend to continue to study this topic.
FiguresFigure 1. Patient stands in front of the camera frame with his right side close to it, and his back close to the vertical plate. The back side of his head, back, buttocks, legs, and both heels are required to cling to the vertical plate surface, which creates the neutral position of natural standing. The neck is placed in the middle line of the irradiation field, and the central line is vertically rayed into the camera frame through the side of the thyroid cartilage. The filming distance and equipment model are the same as those in regular position. Figure 2. A device (Invention patent No.: ZL 201920952467.4) for cervical vertebra physiological curvature protection in natural position is applied for traction. Based on information such as the patient’s image data, height, and weight, traction pillows of specific materials and hardness are made for traction to correct the physiological curvature of the cervical spine and to relax the strained cervical muscles. Figure 3. Regular position. (A) A retroflexion of cervical vertebra was observed. (B) Before treatment, the C2–7 Cobb angle was −11.5°, and the D value was obviously negative. (C) After 12 months’ treatment, the D value was 0.5 mm, which was significantly improved from the previous negative value. Figure 4. Natural position. (A) Before treatment, a retroflexion of cervical vertebra was observed. The C2–7 Cobb angle was −13.5°. (B) After treatment, significant improvement of cervical physiological curvature was observed. The C2–7 Cobb angle was 12°.
1. Kjaer P, Kongsted A, Hartvigsen J, National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy: Eur Spine J, 2017; 26; 2242-57
2. Oh C, Lee M, Hong B, Association between sagittal cervical spinal alignment and degenerative cervical spondylosis: A retrospective study using a new scoring system: J Clin Med, 2022; 11; 1772
3. Zhuang L, Wang L, Xu D, Association between excessive smartphone use and cervical disc degeneration in young patients suffering from chronic neck pain: J Orthop Sci, 2021; 26; 110-15
4. Barrett JM, McKinnon C, Callaghan JP, Cervical spine joint loading with neck flexion: Ergonomics, 2020; 63; 101-8
5. Gutman G, Rosenzweig DH, Golan JD, Surgical treatment of cervical radiculopathy: Meta-analysis of randomized controlled trials: Spine, 2018; 43; E365-72
6. de Campos TF, Maher CG, Steffens D, Exercise programs may be effective in preventing a new episode of neck pain: A systematic review and meta-analysis: J Physiother, 2018; 64; 159-65
7. Cui XJ, Yao M, Ye XL, Shi-style cervical manipulations for cervical radiculopathy: A multicenter randomized-controlled clinical trial: Medicine, 2017; 96; e7276
8. Dedering A, Peolsson A, Cleland JA, The effects of neck-specific training versus prescribed physical activity on pain and disability in patients with cervical radiculopathy: A randomized controlled trial: Arch Phys Med Rehabil, 2018; 99; 2447-56
9. Louw S, Makwela S, Manas L, Effectiveness of exercise in office workers with neck pain: A systematic review and meta-analysis: S Afr J Physiother, 2017; 73; 392
10. Fang Q, Liang DD, Clinical study on treatment of cervical radiculopathy by triangular needling combined with pilates motion therapy: J Jiujiang Univ, 2018; 33; 63-66
11. Zhao , Analysis of the cervical spine alignment and its correlation with spino-pelvic balance in asymptomatic young adults: Chinese Journal of Spine and Spinal Cord, 2015; 25(3); 231-38
12. Gore DR, Gardner GM, Roentgenographic findings of the cervical spine in asymptomatic people: Spine, 1986; 11; 521-24
13. Wu Y, Yao XM, Xu SY, Therapeutic effect of exercise therapy combined with cervical traction and oral application of anti-inflammatory agents on cervical spondylotic radiculopathy: J Tradit Chin Orthop Traumatol, 2014; 26; 24-26
14. Childress MA, Becker BA, Nonoperative management of cervical radiculopathy: Am Fam Physician, 2016; 93; 746-54
15. Leveque JC, Marong-Ceesay B, Cooper T, Diagnosis and treatment of cervical radiculopathy and myelopathy: Phys Med Rehabil Clin N Am, 2015; 26; 491-511
16. Furlan AD, Malmivaara A, Chou R, 2015 updated method guideline for systematic reviews in the Cochrane back and neck group: Spine, 2015; 40; 1660-73
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