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Study on the consistency between CT hounsfield units and MRI evaluation of preoperative cervical paraspinal muscular fat infiltration in patients undergoing ACDF

Journal of Orthopaedic Surgery and Research volume 19, Article number: 435 (2024) Cite this article

Abstract

Objective

To explore the feasibility of applying CT Hounsfield Units (HUs) for the assessment of preoperative paraspinal muscle fat infiltration (FI) in different segments in patients who underwent anterior cervical discectomy and fusion (ACDF). To compare the consistency of preoperative paraspinal muscle FI evaluations using MRI and those via CT HUs in patients who underwent ACDF surgery.

Methods

Ninety-five patients (45 males and 50 females, aged 37‒71 years) who received CT and MRI examinations and underwent ACDF surgery were retrospectively analyzed. In the axial T2-weighted MR images at the median level of the C3/4, C4/5, and C5/6 segments, regions of interests (ROIs) were delineated along the boundaries of the cervical multifidus (MF) and semispinalis cervicis (Scer) muscles. Using the threshold tool in ImageJ software, areas of fat tissue and intermuscular septa within the ROI were quantified. The effective cross-sectional area (ECSA) for each side was obtained by subtracting the areas of fat tissue and intermuscular septa from the total ROI area. The ratio of the fat tissue area to the CSA was then calculated to determine the initial FI value. The depth of subcutaneous fat from the midline spinous process to the epidermis at the median plane of the C4/5 intervertebral disc was measured. The initial FI values were then divided by the depth of fat to determine the post-correction FI value. Using the Picture Archiving and Communication System (PACS), at identical segments and planes, ROIs were delineated using the same method as in MRI under a standard soft tissue window (width of 500 HU, level of 60 HU). The CT HU values were measured within these defined areas. The CT HU values from both sides are summed to obtain the total HU value for the segment. According to whether the measurement results of two sets of data follow a normal distribution, Pearson’s test or Sperman’s test was used to analyze the correlation.

Results

On MRI, a statistically significant difference was observed in the post-correction FI only at the C3/4 segment compared to the other two segments (P < 0.05). No significant difference in the post-correction FI between the C4/5 and C5/6 segments was noted (P > 0.05). The CT HU results showed a substantial discrepancy between C3/4 and C4/5 segments and between C3/4 and C5/6 segments (P < 0.05), whereas no statistically significant difference was found in the CT HU value between the C4/5 and C5/6 segments (P > 0.05). The consistency analysis revealed a relatively strong correlation between the post-correction FI and CT HU values of the C3/4 and C4/5 segments. Furthermore, a strong correlation was detected in the variations in the measurement outcomes at the C5/6 segment.

Conclusion

Patients requiring surgical treatment for the cervical spine exhibit varying degrees of FI in paraspinal muscles across different locations and segments. Evaluating the degree of FI in the paraspinal muscles of the cervical spine through CT HU values is feasible. There is considerable consistency between the post-correction FI assessed under MRI and the measurements of CT HU values in evaluating the FI of paraspinal muscles in the cervical spine.

Introduction

The paraspinal muscles of the cervical spine, commonly located posterior to the cervical vertebrae, encompass a spectrum of muscles, including the deeper multifidus (MF) and semispinalis cervicis (Scer), as well as the more superficial splenius capitis and semispinalis capitis. These muscles play a pivotal role in assisting the cervical spine in executing complex movements such as flexion, translation, and rotation. Furthermore, in conjunction with osseous structures, these structures bear axial stress originating from the skull during daily activities. They are crucial for maintaining the cervical spine in a neutral alignment, ensuring a level gaze, and regulating the dynamic and static equilibrium of the cervical spine’s sagittal plane [1]. This synergistic function underscores their importance in the overall biomechanics and functional stability of the cervical region.

Paraspinal muscle degeneration and fatty infiltration (FI) have emerged as focal points of research in recent years. Studies have demonstrated a correlation between lumbar paraspinal muscle FI and lumbar spine disorders [2, 3], as well as prognosis following lumbar spine surgery [4]. Similarly, investigations into cervical paraspinal muscle FI have confirmed that its severity can detrimentally impact both the local and global sagittal balance of the cervical spine [5] and is associated with conditions such as cervical whiplash injuries [6, 7], neck pain [8], and postoperative axial symptoms after surgery [9]. For patients undergoing cervical spine surgery, the degree of paraspinal muscle degeneration is a critical factor influencing their prognosis [10]. The severity of FI is linked to clinical symptoms and can affect surgical outcomes. Precise preoperative assessment of FI severity aids in identifying contributing factors to FI, thereby facilitating strategies aimed at delaying the progression of cervical paraspinal muscle FI, improving its severity, and preventing its onset.

Currently, the assessment of cervical paraspinal muscle FI primarily relies on MRI [1, 2]. However, due to various limiting factors, a portion of patients are unable to undergo cervical spine MRI. CT HU values have been widely utilized to assess the degree of osteoporosis in patients [11]. Compared to MRI, CT scans offer convenience, shorter examination times, and easier dissemination across different levels of healthcare facilities. The question of whether CT HU values, as reliable indicators of tissue density changes, can be applied to the assessment of cervical paraspinal muscle FI remains open. To address this issue, this study conducted comparative analyses of cervical paraspinal muscle FI across different cervical segments in patients requiring surgical intervention utilizing both MR images and CT HU measurements. The goal of this study was to explore the feasibility of employing CT HU values in the preoperative assessment of cervical paraspinal muscle FI in patients with severe cervical degenerative disease.

Information and methodology

General information

Patients who underwent ACDF surgery at the Department of Orthopaedics III, Dongzhimen Hospital, Beijing University of Chinese Medicine, from January 2019 to April 2023 were retrospectively analyzed. The case inclusion criteria were as follows: (1) fulfilled the diagnostic criteria of symptomatic cervical disc degeneration disease (CDDD) and underwent ACDF surgery; (2) underwent both cervical MRI and CT examinations at our institution with identical equipment preoperatively. The imaging data obtained from these examinations were comprehensive and complete; and (3) The surgical segment is a dual segment: C3/4 and C4/5, or C4/5 and C5/6. Or the surgical segment is triple segments: C3/4, C4/5, and C5/6. The exclusion criteria were as follows: (1) patients treated with alternative surgical techniques; (2) patients who underwent revision surgery; (3) individuals with congenital neck or cervical spine deformities; and (4) patients with conditions such as trauma that could result in injury to the cervical paraspinal musculature. This study was approved by the Medical Ethics Committee of Dongzhimen Hospital, Beijing University of Chinese Medicine (approval number: 2021DZMEC-082-02).

Description of imaging equipment parameters

MRI Imaging: Scans were performed using a 3.0T Philips MRI scanner (Philips, Germany) with a slice thickness of 4 mm and an interslice gap of 0.4 mm. The scanning parameters were set as follows: for TSE T1-weighted images (T1WIs), the repetition time (TR) was 600 ms, and the echo time (TE) was 8 ms; for T2-weighted images (T2WIs), the repetition time (TR) was 2700 ms, and the echo time (TE) was 110 ms; and for STIR sequences, the parameters were TR = 2500 ms, TE = 60 ms, and inversion time (TI) = 150 ms.

CT Imaging: Imaging was conducted using a Siemens dual-source CT scanner. The scanning parameters included a tube voltage of 120 kV and a tube current of 355 mA, with a slice thickness of 5 mm. The window width for soft tissue was set at 400 HU, and the window level was set at 60 HU.

Imaging assessment

In the MR and CT images, the degree of FI in the muscles at the bilateral levels of C3\4, C4\5, and C5\6 was measured for all included patients. All measurements were independently conducted by two orthopedic surgeons. In cases of significant discrepancy between measurements, a third orthopedic surgeon was consulted to assist in finalizing the measurements.

MRI Measurement Method: Within the axial T2-weighted imaging (T2WI) of each spinal segment, at the mid-disc level, ROIs were delineated along the borders of the MF and Scer muscles to calculate the cross-sectional area (CSA) of the muscles. The threshold tool in ImageJ software was used to differentiate fat tissue and muscle septae within the ROI from normal muscle tissue. Specifically, areas occupied by fat tissue and muscle septae were demarcated in red, facilitating their distinction from the surrounding muscle tissue. The effective cross-sectional area (ECSA) was determined by subtracting the area occupied by fat tissue and muscle septum from the ROI area. The ratio of the fat tissue area to the CSA was then calculated to derive the initial FI (Fig. 1). To minimize the impact of individual differences on the results, the depth of fat from the posterior median spinous process to the subcutaneous region at the C4/5 level was measured. The initial FI values were then divided by the depth of fat to determine the post-correction FI value.

Fig. 1
figure 1

a ROIs are delineated along the boundaries of the MF and Scer muscles based on anatomical landmarks. b The threshold tool in ImageJ software is utilized to color the adipose tissue and muscle septa within the ROI, with the red areas representing the combined areas of adipose tissue and muscle septa. c The ECSA of the segment is calculated by subtracting the areas of adipose tissue and muscle septa from the total ROI area. The initial FI is then determined by the ratio of the adipose tissue area to the CSA

Full size image

Using the Picture Archiving and Communication System (PACS), at identical segments and planes, ROIs were delineated using the same method as in MRI under a standard soft tissue window (width of 500 HU, level of 60 HU). The CT HU values were measured within these defined areas. The CT HU values from both sides are summed to obtain the total HU value for the segment (Fig. 2).

Fig. 2
figure 2

The ROIs were delineated on axial CT images using the same methodology applied for MRI. The CT HU values within these ROIs were measured. The CT HU values from both sides are summed to obtain the total HU value for the segment

Full size image

To minimize errors, all MRI and CT HU measurements were independently obtained by two orthopedic surgeons who had undergone specific training for this task. The actual measurement value was determined by taking the average of three separate readings.

Statistical analysis

SPSS 20.0 software was used for statistical analysis, and the data are expressed as the mean ± standard deviation (x ± s). When the data were normally distributed, paired t tests were used to compare the post-correction FI values and CT HU values. The Wilcoxon test was used for the nonnormally distributed parameters. P < 0.05 was considered to indicate a statistically significant difference. According to whether the measurement results of two sets of data follow a normal distribution, Pearson’s test or Sperman’s test was used to analyze the correlation.

Results

In this study, 95 patients with severe cervical degenerative disease who underwent both cervical MRI and CT examinations followed by ACDF surgery at our institution were included. The cohort comprised 45 males and 50 females, with ages ranging from 37 to 71 years (mean age 52.0 ± 7.6 years).

On MRI, a statistically significant difference was observed in the post-correction FI only at the C3/4 segment compared to the other two segments (P < 0.05). No significant difference in the post-correction FI between the C4/5 and C5/6 segments was noted (P > 0.05).

The CT HU results showed a substantial discrepancy between C3/4 and C4/5 segments and between C3/4 and C5/6 segments (P < 0.05), whereas no statistically significant difference was found in the CT HU value between the C4/5 and C5/6 segments (P > 0.05).

The consistency analysis revealed a relatively strong correlation between the post-correction FI and CT HU values of the C3/4 and C4/5 segments. Furthermore, a strong correlation was detected in the variations in the measurement outcomes at the C5/6 segment (Table 1).

Table 1 MRI and CT imaging results (X ± S, n = 95)
Full size table

Discussion

Research on the FI of paraspinal muscles in the cervical spine began later than that of the lumbar spine. In 1994, Hallgren RC [12] and in 1998, Andary MT [13] were the first to draw attention to the correlation between signal intensity changes within cervical muscle tissues and neck symptoms. It was not until 2005 that Elliott [14], through MRI evaluation, advanced the study of cervical paraspinal muscle FI and its degree to a quantitative level. As scholars have deepened their understanding of the crucial role that paraspinal muscles play in both physiological and pathological changes in the cervical spine, related research has progressively expanded.

Currently, the evaluation of FI in the paraspinal muscles of the cervical spine is primarily based on MRI. Compared to MRI, CT has been used in fewer studies evaluating FI in the cervical paraspinal muscles. This may be attributed to the lower sensitivity of CT in distinguishing between muscle and adipose tissue. However, CT also has unique advantages. For patients with acute injuries, CT is a more convenient and essential initial examination. Moreover, the convenience, reduced time consumption, and greater accessibility of CT scans facilitate their adoption across various levels of healthcare facilities. Elliott JM [15] collected immediate postinjury CT images of 36 patients with whiplash-associated disorders (WADs) and conducted cervical spine MRI evaluations at 1 week, 2 weeks, 3 months, and 12 months postinjury. The results demonstrated a close correlation between the attenuation in muscle CT values 1 week postinjury and the degree of FI in corresponding regions on MRI, indicating that patients with more severe injuries exhibited more pronounced FI in the deeper cervical paraspinal muscles at 1 year postinjury. These findings provide some evidence supporting the application of CT values in the evaluation of cervical paraspinal muscle FI. However, in comparison with WAD patients, those requiring surgical intervention exhibit notably different characteristics of paraspinal muscle FI. For patients with severe cervical degenerative diseases, FI in the cervical paraspinal muscles represents a manifestation of muscle degeneration, whereas in WAD patients, FI results from acute and chronic injuries. Therefore, the outcomes of this study do not fully validate the efficacy and feasibility of using CT HU values for evaluating cervical paraspinal muscle FI.

The results of this study suggest that evaluating the FI of cervical paraspinal muscles using HU values from CT scans is feasible, and there is a certain degree of consistency between the post-correction FI in MRI images and the CT HU value measurements for assessing cervical paraspinal muscle FI. HU represents values that correspond with the X-ray attenuation coefficient of tissues in CT imaging [16]. A decrease in the density of degenerated muscle tissue and an increase in fat content manifest in CT images as changes in HU. Due to the convenience of measuring HU values and the ability to selectively target measurement areas, this method has been widely applied in the diagnosis and treatment of conditions such as osteoporosis.

Although this study focused only on the deep cervical MF and Scer muscles, the measurement results from the three segments included suggest that delineating regions based on muscle boundaries in CT images and measuring changes in their HU values can, to a certain extent, reflect the degree of FI in those areas. Cervical paraspinal muscle tissues with more severe FI exhibit lower HU values in CT images. This finding offers a more convenient and faster method for evaluating cervical paraspinal muscle FI.

Additionally, we found that the cervical paraspinal muscles exhibited different degrees of FI at different locations and segments. Both CT HU values and MRI measurements indicated that the degree of FI was more pronounced at the C3/4 segment than at the C4/5 and C5/6 segments. Although Inoue H [17] and Elliott J [15] also observed FI across multiple cervical segments, Inoue H [17] reported that the degree of FI was significantly greater at the C3 and C7 levels than at the C4, C5, and C6 levels. In contrast, Elliott J [15] reported that the level of FI in the MF decreased linearly from C3 to C7. This discrepancy may be attributed to the difference in study populations, with Inoue H [17] focusing on patients with neck pain or radicular symptoms, while Elliott J [15] studied patients with whiplash-associated disorders. A study by Tamai K [18] revealed a significant correlation between muscle volume at the C4 segment and the overall cervical Cobb angle, C7 slope, and T1 slope, suggesting that muscle mass at the C4 segment plays an important role in maintaining the normal physiological curvature of the cervical spine. However, this study was limited to the C4 segment alone. Previous research has not provided a reliable explanation for the observed differences in FI across different segments. Unlike these studies, our research revealed FI in the cervical paraspinal muscles at the intervertebral disc level. We hypothesize that the C3/4 segment, which serves as a transitional area in the posterior cervical muscle group, is more susceptible to muscle injury and aging, making it more prone to FI. Nevertheless, this hypothesis requires further investigation for validation.

The rationale behind selecting the C3/4 to C5/6 segments for this study stems from the fact that the patients included all suffered from severe cervical spondylosis, and these segments are most frequently addressed in cervical spine surgeries. Relevant research on cervical paraspinal muscle FI indicates a certain correlation between the severity of muscle degeneration and the degree of spinal stenosis [19]. Thakar [20] suggested significant atrophy of both flexor and extensor paraspinal muscles in patients with CSM. Although the causal relationship between muscle degeneration, FI, and spinal stenosis remains unclear, these conditions often cooccur. We speculate that for patients with severe cervical spondylosis, if cervical paraspinal muscle FI is further aggravated from its preoperative state, there is a risk of recurrence of stenosis in those segments. Furthermore, accurate preoperative assessment of FI in these patients can aid in developing a more effective and practical rehabilitation plan, potentially delaying or even preventing the worsening of cervical paraspinal muscle FI.

The limitations of this study include the exclusive inclusion of patients with severe cervical degenerative diseases, all of whom exhibited varying degrees of FI in the cervical paraspinal muscles. The absence of a normal control group precludes the precise determination of the critical range for normal CT HU values of cervical paraspinal muscles. Therefore, future research should aim to increase the sample size and perform a statistical analysis on the critical CT HU values for FI in the cervical paraspinal muscles.

Conclusion

Patients requiring surgical treatment for the cervical spine exhibit varying degrees of FI in the paraspinal muscles across different locations and segments. Evaluating the degree of FI in the paraspinal muscles of the cervical spine through CT HU values is feasible. There is considerable consistency between the post-correction FI assessed under MRI and the measurements of CT HU values in evaluating the FI of paraspinal muscles in the cervical spine.

Data availability

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. Department of Orthopedics, Beijing University of Chinese Medicine Dongzhimen Hospital, No. 5, Marine Warehouse, Dongcheng District, Beijing, 100700, China

    Yukun Ma, Dingyan Zhao, Xing Yu, Xinliang Yue, Letian Meng, Luchun Xu, Ziye Qiu, Ningning Feng & Guozheng Jiang

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Contributions

X contributed to the research and design of this article. Y contributed to the first draft of the article. D contributed to organizing, editing, and summarizing the text. Y and D contributed equally to this work. X, L, L contributed to carried out literature search, quality evaluation. Z, N, G contributed to data collection and analysis. All authors agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

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Correspondence to Xing Yu.

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Ma, Y., Zhao, D., Yu, X. et al. Study on the consistency between CT hounsfield units and MRI evaluation of preoperative cervical paraspinal muscular fat infiltration in patients undergoing ACDF. J Orthop Surg Res 19, 435 (2024). https://doi.org/10.1186/s13018-024-04935-1

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Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X