Imaging anatomy study on utilizing uncinate process “inflection point” as a landmark for anterior cervical spine decompression surgery_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

JIANG Jianfeng ¹ , MA Jun ² , YANG Maoyu ² , HAN Yaozheng ² , SU Lintao ² , LEI Changyu ² , GE Chenguang ² ,  KANG Hui ²

1. Medical College, Wuhan University of Science and Technology, Wuhan Hubei, 430065, P. R. China;
2. Department of Orthopedics, General Hospital of Central Theater Command of Chinese PLA, Wuhan Hubei, 430070, P. R. China;

Corresponding?author：

KANG Hui, Email: kanghuicss@163.com

Keywords：

Uncinate process “inflection point”; anterior cervical decompression surgery; localization landmark; anatomical measurement; radiographic study

DOI：

10.7507/1002-1892.202412052

Video：

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Objective To explore the anatomical parameters of the cervical uncinate process “inflection point” through cervical CT angiography (CTA) and MRI measurements, offering a reliable and safe anatomical landmark for anterior cervical decompression surgery. Methods A retrospective analysis was conducted on the cervical CTA and MRI imaging data of normal adults who met the selection criteria between January 2020 and January 2024. The CTA dataset included 326 cases, with 200 males and 126 females, aged 22-55 years (mean, 46.7 years). The MRI dataset included 300 cases, with 200 males and 100 females, aged 18-55 years (mean, 43.7 years). Based on the CTA data, three-dimensional models of C₃-C₇ were constructed, and the following measurements were obtained from the superior view: uncinate process “inflection point” to vertebral artery distance (UIVD), uncinate process tip to vertebral artery distance (UTVD), uncinate process “inflection point” to “inflection point” distance (UID), uncinate process long-axis to sagittal angle (ULSA), and uncinate process “inflection point” to transverse foramen-sagittal angle (UITSA). From the anterior view, the anterior uncinate process to sagittal angle (AUSA) was measured. From the posterior view, the posterior uncinate process to sagittal angle (PUSA) was measured. Based on the MRI data, uncinate process “inflection point” to dural sac distance (UIDD) and dural sac width (DSW) were measured. The trends in measurement parameters of C₃-C₇ were observed, and the differences in measurement parameters between genders and between the left and right sides of the same segment were compared, as well as the difference in UID and DSW within the same segment was compared. Results The measurement parameters from C₃ to C₇ in the CTA data showed a general increasing trend, with no significant difference between the left and right sides within the same segment (P>0.05). The UIVD, UTVD, and UID were greater in males than in females, with significant differences observed in the UIVD and UTVD at C₃ and C₆ and UID at C₃, C₆, and C₇ (P<0.05). The MRI measured DSW showed a general increasing trend from C₃ to C₇, and the DSW at C₆ was greater in females than in males, with a significant difference (P<0.05). The UIDD showed a gradual decreasing trend, with the smallest value at C₆. There was no significant difference between males and females or between the left and right sides within the same segment (P>0.05). The UID was greater than the DSW at C₃-C₇, and the differences were significant (P<0.05). Conclusion The uncinate process “inflection point” is a constant anatomical structure located at the anteromedial aspect of the uncinate process tip and laterally to the dural sac. It maintains a certain safe distance from the vertebral artery. As a decompression landmark in anterior cervical spine surgery, it not only ensures surgical safety but also guarantees complete decompression.

Citation： JIANG Jianfeng, MA Jun, YANG Maoyu, HAN Yaozheng, SU Lintao, LEI Changyu, GE Chenguang, KANG Hui. Imaging anatomy study on utilizing uncinate process “inflection point” as a landmark for anterior cervical spine decompression surgery. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(3): 332-340. doi: 10.7507/1002-1892.202412052 Copy

1.	連曉瑋, 李鵬, 黃世金, 等. 不同年齡C_{3, 4}脊髓型頸椎病患者的臨床特征與影像學對照研究. 中華骨科雜志, 2023, 43(4): 247-256.
2.	Oshina M, Kawamura N, Hara N, et al. A propensity score-matched analysis of clinical outcomes between single-level and multilevel intervertebral decompression for cervical radiculopathy. Spine (Phila Pa 1976), 2023, 48(4): 247-252.
3.	Deng Y, He J, Chen H, et al. Cervical alignment and range of motion change after anterior 3-level Hybrid surgery compared with cervical laminoplasty: a matched cohort study. Orthop Surg, 2024, 16(8): 1893-1902.
4.	Miller AK, Zakko P, Park DK, et al. Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database. Spine J, 2024, 24(5): 791-799.
5.	Park S, Jeong G, Hwang CJ, et al. Laminoplasty with foraminotomy versus anterior cervical discectomy and fusion for cervical myeloradiculopathy. Spine J, 2024, 24(12): 2253-2263.
6.	Ou Y, Lu J, Mi J, et al. Extensive anterior decompression for mixed cervical spondylosis. Resection of uncovertebral joints, neural and transverse foraminotomy, subtotal corpectomy, and fusion with strut graft. Spine (Phila Pa 1976), 1994, 19(23): 2651-2657.
7.	Morris L, Lawless A, McDonnell JM, et al. Retrospective case series of vertebral artery injuries associated with cervical spine trauma. Surgeon, 2024, 22(6): 358-363.
8.	Garg S, Maniakhina L, Muir SM, et al. Preventing iatrogenic injury to the vertebral artery in cervical spine surgery: a case report. Clin Spine Surg, 2024, 37(10): 477-481.
9.	Lunardini DJ, Eskander MS, Even JL, et al. Vertebral artery injuries in cervical spine surgery. Spine J, 2014, 14(8): 1520-1525.
10.	Sun K, Jin L, Zhao B, et al. Radiologic evaluation of uncinate processes of the cervical spine and the relationship between the uncinate process and vertebral artery: implication in anterior cervical spine surgery. World Neurosurg, 2024, 186: e360-e365.
11.	Güven?er M, Naderi S, Men S, et al. Morphometric evaluation of the uncinate process and its importance in surgical approaches to the cervical spine: a cadaveric study. Singapore Med J, 2016, 57(10): 570-577.
12.	Hartman J. Anatomy and clinical significance of the uncinate process and uncovertebral joint: A comprehensive review. Clin Anat, 2014, 27(3): 431-440.
13.	包肖肖, 王龍, 蘇鍇, 等. 三維可視化技術在經皮椎體成形術術后椎體感染病灶清除中的應用. 中華創傷骨科雜志, 2024, 26(7): 631-635.
14.	李琨, 張燕, 郭冉, 等. 兒童及青少年枕頸角與后枕頸角數字化測量及其臨床意義. 中國臨床解剖學雜志, 2024, 42(1): 17-20, 25.
15.	Kong QJ, Sun XF, Wang Y, et al. Risk assessment of vertebral artery injury in anterior controllable antedisplacement and fusion (ACAF) surgery: a cadaveric and radiologic study. Eur Spine J, 2019, 28(10): 2417-2424.
16.	Malik SW, Stemper BD, Metkar U, et al. Location of the transverse foramen in the subaxial cervical spine in a young asymptomatic population. Spine (Phila Pa 1976), 2010, 35(12): E514-E519.
17.	Malla HP, Kim SB, Won JS, et al. Study of the transverse foramen in the subaxial cervical spine in Korean patients with degenerative changes: an anatomical note. Neurospine, 2018, 15(2): 163-168.
18.	Wang S, Zhang YN, Yang X, et al. Anatomic research of the safe space between the cervical uncinate process and the V2 vertebral artery. World Neurosurg, 2024, 191: e713-e722.
19.	Post NH, Cooper PR, Frempong-Boadu AK, et al. Unique features of herniated discs at the cervicothoracic junction: clinical presentation, imaging, operative management, and outcome after anterior decompressive operation in 10 patients. Neurosurgery, 2006, 58(3): 497-501.
20.	Yamazaki S, Kokubun S, Ishii Y, et al. Courses of cervical disc herniation causing myelopathy or radiculopathy: an analysis based on computed tomographic discograms. Spine (Phila Pa 1976), 2003, 28(11): 1171-1175.
21.	Yoganandan N, Purushothaman Y, Choi H, et al. Biomechanical effects of uncinate process excision in cervical disc arthroplasty. Clin Biomech (Bristol), 2021, 89: 105451. doi: 10.1016/j.clinbiomech.2021.105451.
22.	楊毅, 劉浩, 吳廷奎, 等. 鉤椎關節應用解剖測量及輔助鉤椎關節融合器參數設計. 中國修復重建外科雜志, 2019, 33(12): 1491-1497.
23.	Zhu YH, Cheng KL, Zhong Z, et al. Morphologic evaluation of Chinese cervical endplate and uncinate process by three-dimensional computed tomography reconstructions for helping design cervical disc prosthesis. J Chin Med Assoc, 2016, 79(9): 500-506.
24.	Kocabiyik N, Ercikti N, Tunali S. Morphometric analysis of the uncinate processes of the cervical vertebrae. Folia Morphol (Warsz), 2017, 76(3): 440-445.
25.	張德洲, 王超群, 史君, 等. 頸椎鉤突相關夾角增齡變化的特征與意義. 中國組織工程研究, 2024, 28(36): 5766-5772.
26.	Zhu J, Feng D, Song D, et al. Effect of anterior cervical decompression fusion and partial resection of uncinate vertebra joint on cervical sagittal sequence in patients with non-single-segment radiculopathy and its correlation with curative effect: a retrospective analysis. Orthop Surg, 2023, 15(4): 1085-1095.
27.	Yang JJ, Kim HJ, Lee JB, et al. Preoperative radiographic simulation for partial uncinate process resection during anterior cervical discectomy and fusion to achieve adequate foraminal decompression and prevention of vertebral artery injury. Asian Spine J, 2023, 17(6): 1024-1034.
28.	Park MS, Moon SH, Kim TH, et al. surgical anatomy of the uncinate process and transverse foramen determined by computed tomography. Global Spine J, 2015, 5(5): 383-390.

1. 連曉瑋, 李鵬, 黃世金, 等. 不同年齡C_{3, 4}脊髓型頸椎病患者的臨床特征與影像學對照研究. 中華骨科雜志, 2023, 43(4): 247-256.
2. Oshina M, Kawamura N, Hara N, et al. A propensity score-matched analysis of clinical outcomes between single-level and multilevel intervertebral decompression for cervical radiculopathy. Spine (Phila Pa 1976), 2023, 48(4): 247-252.
3. Deng Y, He J, Chen H, et al. Cervical alignment and range of motion change after anterior 3-level Hybrid surgery compared with cervical laminoplasty: a matched cohort study. Orthop Surg, 2024, 16(8): 1893-1902.
4. Miller AK, Zakko P, Park DK, et al. Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database. Spine J, 2024, 24(5): 791-799.
5. Park S, Jeong G, Hwang CJ, et al. Laminoplasty with foraminotomy versus anterior cervical discectomy and fusion for cervical myeloradiculopathy. Spine J, 2024, 24(12): 2253-2263.
6. Ou Y, Lu J, Mi J, et al. Extensive anterior decompression for mixed cervical spondylosis. Resection of uncovertebral joints, neural and transverse foraminotomy, subtotal corpectomy, and fusion with strut graft. Spine (Phila Pa 1976), 1994, 19(23): 2651-2657.
7. Morris L, Lawless A, McDonnell JM, et al. Retrospective case series of vertebral artery injuries associated with cervical spine trauma. Surgeon, 2024, 22(6): 358-363.
8. Garg S, Maniakhina L, Muir SM, et al. Preventing iatrogenic injury to the vertebral artery in cervical spine surgery: a case report. Clin Spine Surg, 2024, 37(10): 477-481.
9. Lunardini DJ, Eskander MS, Even JL, et al. Vertebral artery injuries in cervical spine surgery. Spine J, 2014, 14(8): 1520-1525.
10. Sun K, Jin L, Zhao B, et al. Radiologic evaluation of uncinate processes of the cervical spine and the relationship between the uncinate process and vertebral artery: implication in anterior cervical spine surgery. World Neurosurg, 2024, 186: e360-e365.
11. Güven?er M, Naderi S, Men S, et al. Morphometric evaluation of the uncinate process and its importance in surgical approaches to the cervical spine: a cadaveric study. Singapore Med J, 2016, 57(10): 570-577.
12. Hartman J. Anatomy and clinical significance of the uncinate process and uncovertebral joint: A comprehensive review. Clin Anat, 2014, 27(3): 431-440.
13. 包肖肖, 王龍, 蘇鍇, 等. 三維可視化技術在經皮椎體成形術術后椎體感染病灶清除中的應用. 中華創傷骨科雜志, 2024, 26(7): 631-635.
14. 李琨, 張燕, 郭冉, 等. 兒童及青少年枕頸角與后枕頸角數字化測量及其臨床意義. 中國臨床解剖學雜志, 2024, 42(1): 17-20, 25.
15. Kong QJ, Sun XF, Wang Y, et al. Risk assessment of vertebral artery injury in anterior controllable antedisplacement and fusion (ACAF) surgery: a cadaveric and radiologic study. Eur Spine J, 2019, 28(10): 2417-2424.
16. Malik SW, Stemper BD, Metkar U, et al. Location of the transverse foramen in the subaxial cervical spine in a young asymptomatic population. Spine (Phila Pa 1976), 2010, 35(12): E514-E519.
17. Malla HP, Kim SB, Won JS, et al. Study of the transverse foramen in the subaxial cervical spine in Korean patients with degenerative changes: an anatomical note. Neurospine, 2018, 15(2): 163-168.
18. Wang S, Zhang YN, Yang X, et al. Anatomic research of the safe space between the cervical uncinate process and the V2 vertebral artery. World Neurosurg, 2024, 191: e713-e722.
19. Post NH, Cooper PR, Frempong-Boadu AK, et al. Unique features of herniated discs at the cervicothoracic junction: clinical presentation, imaging, operative management, and outcome after anterior decompressive operation in 10 patients. Neurosurgery, 2006, 58(3): 497-501.
20. Yamazaki S, Kokubun S, Ishii Y, et al. Courses of cervical disc herniation causing myelopathy or radiculopathy: an analysis based on computed tomographic discograms. Spine (Phila Pa 1976), 2003, 28(11): 1171-1175.
21. Yoganandan N, Purushothaman Y, Choi H, et al. Biomechanical effects of uncinate process excision in cervical disc arthroplasty. Clin Biomech (Bristol), 2021, 89: 105451. doi: 10.1016/j.clinbiomech.2021.105451.
22. 楊毅, 劉浩, 吳廷奎, 等. 鉤椎關節應用解剖測量及輔助鉤椎關節融合器參數設計. 中國修復重建外科雜志, 2019, 33(12): 1491-1497.
23. Zhu YH, Cheng KL, Zhong Z, et al. Morphologic evaluation of Chinese cervical endplate and uncinate process by three-dimensional computed tomography reconstructions for helping design cervical disc prosthesis. J Chin Med Assoc, 2016, 79(9): 500-506.
24. Kocabiyik N, Ercikti N, Tunali S. Morphometric analysis of the uncinate processes of the cervical vertebrae. Folia Morphol (Warsz), 2017, 76(3): 440-445.
25. 張德洲, 王超群, 史君, 等. 頸椎鉤突相關夾角增齡變化的特征與意義. 中國組織工程研究, 2024, 28(36): 5766-5772.
26. Zhu J, Feng D, Song D, et al. Effect of anterior cervical decompression fusion and partial resection of uncinate vertebra joint on cervical sagittal sequence in patients with non-single-segment radiculopathy and its correlation with curative effect: a retrospective analysis. Orthop Surg, 2023, 15(4): 1085-1095.
27. Yang JJ, Kim HJ, Lee JB, et al. Preoperative radiographic simulation for partial uncinate process resection during anterior cervical discectomy and fusion to achieve adequate foraminal decompression and prevention of vertebral artery injury. Asian Spine J, 2023, 17(6): 1024-1034.
28. Park MS, Moon SH, Kim TH, et al. surgical anatomy of the uncinate process and transverse foramen determined by computed tomography. Global Spine J, 2015, 5(5): 383-390.

Chinese Journal of Reparative and Reconstructive Surgery

Imaging anatomy study on utilizing uncinate process “inflection point” as a landmark for anterior cervical spine decompression surgery

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