Incidence and age and gender profiles of hyperplasia in individual cervical vertebrae
Downloaded from imr.sagepub.com by guest on July
Incidence and age and gender profiles of hyperplasia in individual cervical vertebrae
Objective: To analyze the incidence and age and gender profiles of hyperplasia in individual cervical vertebrae. Methods: In this retrospective study, computed tomography three-dimensional reconstruction images of cervical vertebrae from patients with neck discomfort were analyzed for the presence of hyperplasia and compared with age and gender data. Results: Scans from a total of 580 patients (352 males, 228 females) were analyzed. The highest incidence of hyperplasia was seen in C2 (25%), followed by C1 (23%), C6 (16%), C5 (15%), C7 (9%), C4 (8%) and C3 (4%). Patients with C2 hyperplasia were the youngest and those with C1 hyperplasia were the second youngest, while patients with C7 hyperplasia were the oldest. Of those with C2, C1 and C7 hyperplasia, males were significantly younger than females, whereas of those with C3, C4, C5 and C6 hyperplasia, females were significantly younger than males. Conclusions: Hyperplasia of the cervical spine shows different age and gender profiles among the seven vertebrae. These findings may be helpful for the early recognition of cervical hyperplasia and highlight the importance of protecting the atlanto-axial joint in daily life.
eol>Cervical vertebrae; hyperplasia; age; gender
Hyperplasia of the cervical vertebrae is a
common condition in middle aged and
elderly people.1 However, with changes
such as increased time spent working at a
desk or driving, resulting in long periods of
inactivity with a poor posture, the morbidity
of this disease is increasing year on year,
1School of Medicine, Shandong University, Jinan, Shandong
2Department of Radiology, Taian City Central Hospital,
Shandong Province, China
*Min Li and Shuyong Liu are the co-first authors of this
with patients becoming progressively
younger.2,3 Cervical hyperplasia has
commonly been reported in cervical vertebrae
C4, C5, C6 and C7,4 but such reports are
often based on conventional X-ray plain
films, which do not show the upper cervical
spine (C1 and C2) clearly.5 The use of
computed tomography (CT), together with
multiplanar reconstruction, provides a clear
image of all seven cervical vertebrae without
any blind areas. The present study aimed to
investigate differences associated with age
and gender in the incidence of hyperplasia in
individual cervical vertebrae as seen on CT
multiplanar reconstruction images.
Patients and methods
Data from consecutive patients presenting
with neck discomfort who had undergone
64-section spiral CT of the cervical spine
between January 2010 and December 2012
at the Department of Radiology, Taian City
Central Hospital, Shandong Province, China,
were retrieved retrospectively. Patients with a
history of trauma of the cervical spine,
infective or inflammatory conditions of the spine,
cervical tumours, dysplasia, metabolic disease
or surgical procedures of the cervical spine
were excluded from the study.
The study protocol was approved by the
Ethics Committee of the Taian City Central
Hospital, Shandong Province, China. The
requirement for patient consent was waived
due to the retrospective nature of the study.
All patients had undergone a 64-section
spiral CT scan of the cervical spine in a
supine position with the head advanced
using a SOMATOM Sensation 64 CT
scanner (Siemens, Erlangen, Germany). The
scanning parameters used were a tube
current of 300 mA, a tube voltage of 120 kV, a
scan slice of 3.0 mm, a scan interval of
3.0 mm, a sharp kernel (B60s) and a field
of view of 155 155 mm. After routine
scanning, three-dimensional reconstruction
was performed using a slice thickness of
0.75 mm and an increment of 0.7 mm.
Cervical hyperplasia was defined as the
presence of one or more of the following
features on the CT scan: lip-like or lace-like
appearance of the anterior, posterior,
superior or inferior edge of the vertebral body,
lace-like appearance , osteophytes or a bone
bridge formed by fusion of two adjacent
osteophytes.6 CT scans were analyzed
independently by two experienced radiologists
(Q.K. and S.L.) who were blinded to each
other’s assessment and to the patient’s
information. Any discrepancy was resolved
Data was presented as the number of
patients or as the mean SD. Associations
between age and gender and the presence of
hyperplasia in different cervical vertebrae
were analyzed using one-way analysis of
variance and the 2-test. A P-value < 0.05
was considered to be statistically significant.
All statistical analyses were performed using
SPSS software version 17 (SPSS Inc.,
Chicago, IL, USA).
A total of 580 patients were included in the
study; of these, 352 were male and 228 were
female. They ranged in age from 13 to
70 years, with a mean age of 38.5 years.
A total of 1 356 hyperplastic vertebrae
were seen on computed tomography
(Figure 1). The distribution of hyperplasia
in the individual cervical vertebrae is given
in Table 1. Hyperplasia occurred with the
highest frequency in C2 (25%), followed by
C1 (23%), C6 (16%), C5 (15%), C7 (9%),
C4 (8%) and C3 (4%). Hyperplasia was
significantly more likely to occur in C1 and
C2 than in the other cervical vertebrae
(P < 0.05). The incidence of hyperplasia
was higher in females than in males in C1,
C2, C5, C6 and C7 (P < 0.05).
The mean SD ages of patients with
hyperplasia according to the cervical vertebra
affected are given in Table 2 and Figure 2.
There was a significant difference (P < 0.05) in
the age of patients according to the cervical
vertebra affected, with patients with C2
hyperplasia being the youngest, followed by patients
with C1 hyperplasia, while patients with C7
hyperplasia were the oldest (Table 2). In
patients with C2, C1 or C7 hyperplasia, male
patients were significantly younger than
female patients, while in patients with C3,
C4, C5 or C6 hyperplasia, female patients
were significantly younger than male patients.
Hyperplasia of the upper cervical spine
vertebrae and of the posterior edge of
vertebrae in the lower cervical spine are
difficult to detect using plain film X-rays.5,7,8
In contrast, CT multiplanar reconstruction
is able to show the detailed structure of the
vertebral bodies5,9–13 and was therefore used
in the present study to document
hyperplasia of the cervical vertebrae.
Previous studies have reported that
hyperplasia of C1 and C2 (the atlas and axis) is seen
mostly in patients with cervical spine
symptoms aged 40–57 years, with C2 being
the last of the cervical vertebrae to develop
hyperplasia.2,6,14,15 In the present study,
hyperplasia of C1 and C2 was seen at a
mean SD age of 47.97 13.23 years and
44.12 19.98 years, respectively, which is
consistent with previous studies, and occurred
at a younger age in male compared with
female patients. In addition, hyperplasia
occurred with the highest frequency in C2,
followed by C1, C6, C5, C7, C4 and C3,
which is in contrast to previously published
reports. However, in most of the previously
reported studies, conventional plain film
Xrays were used, in which the upper cervical
spine overlaps with maxillofacial structures.
As a result, such films only show the distance
between the odontoid process of the axis and
the lateral mass of the atlas, with mild bone
hyperplasia being poorly demonstrated.5,7,8
In the present study CT multiplanar
threedimensional reconstruction was used, which
is the gold standard for the detection of
osteoarthritis of C1 and C2.10 In addition,
few studies have focused on the C1/C2 region,
although these joints make a significant
contribution to the mobility of the spine.16–18
The present study revealed that C2 is the
earliest and the most frequently affected
vertebra in cervical hyperplasia, followed by C1.
Age (years) 30
Male, no hyperplasia
Female, no hyperplasia
Total, no hyperplasia
This may be explained by the anatomical
relationships of the cervical vertebrae and
their movements. The cervical spine moves
more than 600 times each hour,2 with
considerable impact on the atlas and axis. C1 and C2
are highly specialized vertebrae that provide
considerable mobility for the skull and
cervical spine in terms of rotation, flexion and
extension.19 A greater degree of rotation is
possible at the atlanto-axial joint than between
the other cervical vertebrae. Rotation occurs
around the odontoid process, with a range of
movement of about 45 . As a whole, the neck
can rotate up to 90 , half of which occurs at
the atlanto-axial joint,20,21 with the other half
being due to rotation of the other cervical
vertebrae. Once the head and upper cervical
vertebrae have rotated by 20–30 , the lower
cervical vertebrae then rotate in order to
complete the entire 90 rotation. The atlas
and axis are therefore involved early in
cervical movements and are responsible for a
large part of the activity range of the neck.
The present study also found that C7 was
the last vertebrae to show hyperplasia. This
may due to the fact that C7 mobility is less
than that of the other cervical vertebrae.
In the present study, hyperplasia in C1,
C2 and C7 occurred at a younger age in
males than in females, whereas hyperplasia
in C3, C4, C5 and C6 occurred at a younger
age in females than in males. In addition, the
incidence of hyperplasia was higher in
females than in males in C1, C2, C5, C6
and C7. The reasons for these differences are
not clear and warrant further study.
One major weakness of the present study
is its retrospective design, with the
possibility of selection bias. In addition, the study
focused on bone hyperplasia and did not
consider changes to the intervertebral discs
or early cystic degenerative changes in the
odontoid process,3 and the hyperplasia was
not graded. The study also did not analyze
other factors that may affect bone
hyperplasia, such as occupation and hormone levels.
Lastly, the study did not investigate the
relationship between hyperplasia seen on
CT images and clinical symptoms.
In conclusion, the present study showed
the pattern of development of cervical
vertebra hyperplasia, with associated differences
in age and gender. C2 was the most
frequently affected vertebra, with a female
predominance. These findings may be helpful
for the early recognition of cervical
hyperplasia and highlight the importance of
protecting the atlanto-axial joint in daily life.
Declaration of conflicting interests
The authors declare that there is no conflict of
This research received no specific grant from any
funding agency in the public, commercial, or
1. Zhang A , Yin S and Xia J. X-ray analysis of cervical spine in 334 patients . Chin J Convalescent Med 2007 ; 3 : 172 - 174 .
2. Badve SA , Bhojraj S , Nene A , et al. Occipitoatlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population . Spine (Phila Pa 1976 ) 2010 ; 35 : 434 - 438 .
3. Betsch MW , Blizzard SR , Shinseki MS , et al. Prevalence of degenerative changes of the atlanto-axial joints . Spine J 2015 ; 15 : 275 - 280 .
4. Berlemann U , Laubli R and Moore RJ . Degeneration of the atlanto-axial joints: a histological study of 9 cases . Acta Orthop Scand 2002 ; 73 : 130 - 133 .
5. Liu K , Lu Y , Cheng D , et al. The prevalence of osteoarthritis of the atlanto-odontoid joint in adults using multidetector computed tomography . Acta Radiol 2014 ; 55 : 95 - 100 .
6. Zapletal J , Hekster RE , Straver JS , et al. Atlanto-odontoid osteoarthritis. Appearance and prevalence at computed tomography . Spine (Phila Pa 1976 ) 1995 ; 20 : 49 - 53 .
7. Zapletal J and de Valois JC . Radiologic prevalence of advanced lateral C1-C2 osteoarthritis . Spine (Phila Pa 1976 ) 1997 ; 22 : 2511 - 2513 .
8. Zapletal J , Hekster RE , Wilmink JT , et al. Atlantoodontoid osteoarthritis: comparison of lateral cervical projection and CT . Eur Spine J 1995 ; 4 : 238 - 241 .
9. Novelline RA , Rhea JT , Rao PM , et al. Helical CT in emergency radiology . Radiology 1999 ; 213 : 321 - 339 .
10. Genez BM , Willis JJ , Lowrey CE , et al. CT findings of degenerative arthritis of the atlantoodontoid joint . AJR Am J Roentgenol 1990 ; 154 : 315 - 318 .
11. Tsukagoshi S , Ota T , Fujii M , et al. Improvement of spatial resolution in the longitudinal direction for isotropic imaging in helical CT . Phys Med Biol 2007 ; 52 : 791 - 801 .
12. Fishman EK and Lawler LP . CT angiography: principles, techniques and study optimization using 16-slice multidetector CT with isotropic datasets and 3D volume visualization . Crit Rev Comput Tomogr 2004 ; 45 : 355 - 388 .
13. van Meurs JB and Uitterlinden AG . Osteoarthritis year 2012 in review: genetics and genomics . Osteoarthritis Cartilage 2012 ; 20 : 1470 - 1476 .
14. Lestini WF and Wiesel SW . The pathogenesis of cervical spondylosis . Clin Orthop Relat Res 1989 ; 239 : 69 - 93 .
15. Rudy IS , Poulos A , Owen L , et al. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study . Chiropr Man Therap 2015 ; 23 : 9 .
16. Adams LP , Tregidga A , Driver-Jowitt JP , et al. Analysis of motion of the head . Spine (Phila Pa 1976 ) 1994 ; 19 : 266 - 271 .
17. Penning L. Normal movements of the cervical spine . AJR Am J Roentgenol 1978 ; 130 : 317 - 326 .
18. Robertson PA , Tsitsopoulos PP , Voronov LI , et al. Biomechanical investigation of a novel integrated device for intra-articular stabilization of the C1-2 (atlantoaxial) joint . Spine J 2012 ; 12 : 136 - 142 .
19. White AA and Panjabi MM. Clinical biomechanics of the spine . 2nd ed. Philadephia: JB Lippincott , 1990 , pp. 92 - 97 .
20. Lakshmanan P , Jones A , Howes J , et al. CT evaluation of the pattern of odontoid fractures in the elderly - relationship to upper cervical spine osteoarthritis . Eur Spine J 2005 ; 14 : 78 - 83 .
21. Iai H , Goto S , Yamagata M , et al. Threedimensional motion of the upper cervical spine in rheumatoid arthritis . Spine (Phila Pa 1976 ) 1994 ; 19 : 272 - 276 .