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Cervical spine changes in goitres
ClinicalRadiology(1982) 33, 25-29 © t982 Royal College of Radiologists
0009-9260/82/01550025502.00
Cervical Spine Changes in Goitres FUNSHO KOMOLAFE
Department of Radiology, University CollegeHospital, Ibadan, Nigeria The cervical spine was studied in neck radiographs of 160 unselected patients with goitre and in 100 controls. Anterior marginal osteophytes were observed in 37.5% of the goitre patients and in 17% of the controls. Straightening or reversal of cervical lordosis occurred in 29.4% of patients with goitre and only 8% of controls, with none of the control group showing reversal of cervical curvature. The changes are thought to be due to stresses imposed on the cervical spine as a result of a continuous reflex attempt to bend the neck forwards and reduce pressure on the trachea from the enlarged thyroid gland. Certain cervical spine changes were frequently observed by the author on lateral neck radiographs of patients with goitres. As part of a radiological study of goitres, it was decided to quantify these changes and to suggest reasons for their appearance.
MATERIALS AND METHODS A total of 160 unselected patients with goitres seen at the University College Hospital, Ibadan, Nigeria, over a 2-year period (June 1977-June 1979) were studied. Antero-posterior (AP) and lateral views of the neck as well as a chest radiograph were obtained in all of the patients. The neck radiographs were taken at a focus-film distance of 90 cm (36 in) for the AP and 180 cm (72 in) for the lateral view, a longer focus-film distance being employed in the latter to compensate for the increased object-film distance that occurs in that projection. All the lateral films were obtained erect with the chin up and the neck extended. All relevant clinical, laboratory, surgical and histological data on the patients were obtained from their hospital records. The 160 patients were made up of 140 females and 20 males. A control group of 100 patients (60 females, 40 males) who had radiographs of the neck obtained in the same period was studied. The clinical indications for requesting neck radiography in the control group include radicular pains or paraesthesiae in the arm thought to be secondary to cervical spine disease or cervical ribs; localisation of swallowed foreign body, or for vague pains in the neck. All neck radiographs performed for trauma were excluded from the control group.
compared with 17 (17%) of the controls. In the goitre group, of the 132 vertebrae in which osteophytes were observed, the fifth cervical vertebra (C5) was most frequently involved, constituting 43.2% (57 vertebrae). This was followed by C4 with 20% (27 vertebrae) and C6 with 18.2% (24 vertebrae). The distribution of osteophytes by vertebrae is illustrated in Fig. 4. The percentage of patients showing osteophytes in each age group is compared in patients with goitre
RESULTS Anterior Marginal Osteophytes Anterior marginal osteophytes (Figs 1, 2, 3) were observed in 60 (37.5%) of the patients with goitre,
Fig. 1 - Lateral neck radiograph of a 45-year-old man. Anterior marginal osteophytes are noted from C4 to C6 with minimal associated disc space reduction. A nodular calcification is noted within the goitre.
26
CLINICAL RADIOLOGY
.&.,
£-
60
2. t4=,
o ~
13
.El 4-, > r
6 z Fig. 2 - Forty-year-old female. Osteophytes are present on C4, 5 and 6. The osteophytes in this patient appear detached.
1~2 3 /., 5 6 7 Cervical vertebral number. Fig. 4 - Histogram illustrating the distribution of marginal osteophytes by vertebrae. A total o f 132 vertebrae were involved. Note that C5 is predominantly affected.
and in controls (Table 1). In only 146 goitre patients and 84 controls was adequate information about patient's age provided. There is overall a significantly higher prevalence of osteophytes in patients with goitre than in controls (Table 2). When broken down into specific age groups (Table 3), 16.7% of goitre patients up to 30 years of age had osteophytes, whereas none of the controls in this age group showed this feature. However, after the age of 50 years, although the prevalence of cervical osteophytes remains higher in goitre patients than in controls, the difference is not statistically significant (Table 3). Although intervertebral disc-space narrowing was frequently observed in association with osteophytes, in most cases marginal osteophytes occurred without disc narrowing. An attempt was made to relate the presence of osteophytes to duration of thyroid swelling, but no correlation was found. Changes in Cervical Curvature Fig. 3 - Thirty-year-old female. Marginal osteophytes are again noted on C4, 5 and 6, although the thyroid is only moderately enlarged.
Straightening or frank reversal of normal cervical lordosis was frequently observed. These features were
CERVICAL SPINE CHANGES IN GOITRE_S
27
Table 1 - Cervical osteophytes in relation to age in patients with goitre and in controls Controls
Goitre patients Age (y ears)
10-20 21-30 31-40 41-50 51-60 O~r60 Grand total
Total no. o f patients
No. with osteophytes
Percentage
No. with o steophy tes
Percentage
Total no. o f con trois
12 30 37 38 20 9
0 7 15 16 13 8
0 23.3 40.5 42.0 65.0 89.0
18 21 21 15 7 2
0 0 5 3 4 2
0 0 23.8 20 57 100
146
39
40.4
84
14
16.7
~
Table 2 - Overall prevalence of osteophytes in patients with goitre and in controls Go#re patients
Controls
Total
59 87
14 70
73 157
146
84
230
No. with osteophytes No. without osteophytes Total Percentage with osteophytes
40.4
16.7
×2 = 13.38 on 1 d.f.;P < 0.001 (d.f. = degrees of freedom).
noted in 47 (29.4%) of the patients with goitre, 38 o f whom had straightening (Figs 5, 6) and nine showed reversal of cervical lordosis (Figs 7, 8). In the control group, only eight patients (8%) showed straightening, but reversal of cervical curvature was not present in any. In several o f the patients with goitre the reversal of curvature was limited only to the vertebrae directly related to the thyroid swelling, i.e. C5 to C7, with the upper cervical vertebrae maintaining a normal alignment (Fig. 7).
DISCUSSION
Except in association with trauma, the cervical spine normally maintains its lordosis, even in the presence of advanced disc degeneration (Hadley, 1964). The apex of the lordosis is formed b y C4 and C5, and the m a x i m u m range o f movement occurs at C5 and C6 (Bowden e t al. 1967). It is therefore not surprising that cervical spondylotic changes occur most frequently at C5 and in the immediately adjoining vertebrae (Hadley, 1964). The distribution o f marginal osteophytes in patients with goitre also conforms to this pattern (Fig. 4). The pressure on the trachea from an enlarged thyroid gland produces varying degrees of discomfort and airway obstruction. It is suggested that part o f the patient's response to the pressure effect o f the goitre is to flex the neck in a reflex attempt to reduce the compression on the trachea This attempt may successfully produce radiologically obvious straightening or fraflk reversal of cervical lordosis or impose such additional stresses on the cervical spine as to predispose to cervical spondylosis, manifested as marginal osteophytes. It is noteworthy that in several cases the reversal of curvature was limited to the
Table 3 - Goitre patients vs. controls: prevalence of osteophytes in specific age groups Age (years)
10-30
Over 50
31-50
Controls
Total
Controls Total
Patients
Controls
No. with osteophytes No. without osteophytes
7 35
0 39
7 74
31 44
8 28
39 72
21
6
8
3
27 11
Total
42
39
81
75
36
111
29
9
38
41.3
22.2
Percentage with osteophytes 16.7
0
X2 = 7.11 on 1 d.f.; P < 0.001
×2 = 3.90 on 1 d.f.; 0.05 > P > 0.02
Total
Patients
Patients
72.4
66.7
×2 = 0.11 on 1 d.f.; P > 0.05 (not significant)
28
CLINICAL RADIOLOGY
Fig. 5 - Thirty-two-year old female, with goitre of 8 years duration. The cervical lordosis is straightened but no osteophytes are present.
Fig. 6 - Fifteen-year-old girl. The cervical lordosis is lost.
cervical spine region w h e r e t h e t h y r o i d mass (and t h e r e f o r e its pressure e f f e c t ) was m a x i m a l (Fig. 7). B o t h marginal o s t e o p h y t e s and even reversal o f cervical lordosis are f r e q u e n t l y o b s e r v e d in illustrations
Fig. 7 - Fifty-year-old female. There is localised reversal of the cervical lordosis at the region of C5 to C7. Note severe sagittal narrowing and posterior displacement of the trachea by the goitre, corresponding to the level of reversal.
Fig. 8 - Lateral neck radiograph in a 13-year-old girl, showing total reversal of the normal cervical curvature. There is a la~g~ retrotracheal extension of the goitre. Note also a noduN calcification within the goitre at the thoracic inlet.
CERVICAL SPINE CHANGES IN GOITRES accompanying publications on goitres, with no comments made about them, e.g. Erazo and Wahner (1966). Reversal of cervical lordosis (arcual kyphosis) is also well recognised as a result of reflex spasm o f paraspinal muscle groups following trivial injury to the neck or upper respiratory tract infection (Penning, 1964). Although the antero-posterior and lateral films performed for the goitre patients are not adequate for assessment of cervical spondylosis, no clinical indication existed to justify obtaining further views. Marginal anterior osteophytes are less likely to produce symptoms, compared with posterior and postero-lateral osteophytes which can produce pressure symptoms on the cervical cord and nerve roots respectively (McRae, 1960). The incidence of cervical spondylosis increases steadily with age and may be as high as 80% in persons over 55 years of age (Brain, 1963). This variation with age is also borne out by the results displayed in Table 1. It is remarkable that of the patients in the control group who did not exceed 30 years of age, none had osteophytes, whereas osteophytes were present in almost 17% of patients with goitre in the same age group (Tables 1,3). After the age of 50 years, the difference in the prevalence of marginal cervical osteophytes ceases to be significantly different
29
between the two groups (Table 3), obviously because after this age the high incidence of degenerative disease becomes the predominant factor. Acknowledgements. I am grateful to Professor O. Ayeni of the Department of Preventive and Social Medicine, University of Ibadan, for his assistance in statistical analysis of the data. I also wish to thank Mr S. C. Alozie for secretarial assistance.
REFERENCES
Bowden, R. E., AbduUah, S. & Gooding, M. R. (1967). Anatomy of the cervical spine membrances, spinal cord, nerve roots and brachial plexus. In Cervical Spondylosis, ed. Brain, L. & Wilkinson, M.~ pp. 54 55. William Heinemann Ltd., London. Brain, L. (1963). Some unsolved problems of cervical spondylosis. British Medical Journal, 1,771-777. Erazo, S. T. & Wahner, H. W. (1966). Roentgenographic diagnosis of thyroid cancer in the presence of endemic goitre. American Journal of R oentgenology , 96,596-603. Hadley, L. A. (1964). Anatomieo-Roentgenographie Studies o f the Spine, pp. 123-124. Charles C. Thomas, Springfield, Illinois. McRae, D. L. (1960). The significance of abnormalities of the cervical spine. American Journal of Roentgenology, 84, 3-25. Penning, L. (1964). Non-pathologic and pathologic relationships between the lower cervical vertebrae. American Journal of Roentgenology, 91, 1036-1050.
0009-9260/82/01550025502.00
Cervical Spine Changes in Goitres FUNSHO KOMOLAFE
Department of Radiology, University CollegeHospital, Ibadan, Nigeria The cervical spine was studied in neck radiographs of 160 unselected patients with goitre and in 100 controls. Anterior marginal osteophytes were observed in 37.5% of the goitre patients and in 17% of the controls. Straightening or reversal of cervical lordosis occurred in 29.4% of patients with goitre and only 8% of controls, with none of the control group showing reversal of cervical curvature. The changes are thought to be due to stresses imposed on the cervical spine as a result of a continuous reflex attempt to bend the neck forwards and reduce pressure on the trachea from the enlarged thyroid gland. Certain cervical spine changes were frequently observed by the author on lateral neck radiographs of patients with goitres. As part of a radiological study of goitres, it was decided to quantify these changes and to suggest reasons for their appearance.
MATERIALS AND METHODS A total of 160 unselected patients with goitres seen at the University College Hospital, Ibadan, Nigeria, over a 2-year period (June 1977-June 1979) were studied. Antero-posterior (AP) and lateral views of the neck as well as a chest radiograph were obtained in all of the patients. The neck radiographs were taken at a focus-film distance of 90 cm (36 in) for the AP and 180 cm (72 in) for the lateral view, a longer focus-film distance being employed in the latter to compensate for the increased object-film distance that occurs in that projection. All the lateral films were obtained erect with the chin up and the neck extended. All relevant clinical, laboratory, surgical and histological data on the patients were obtained from their hospital records. The 160 patients were made up of 140 females and 20 males. A control group of 100 patients (60 females, 40 males) who had radiographs of the neck obtained in the same period was studied. The clinical indications for requesting neck radiography in the control group include radicular pains or paraesthesiae in the arm thought to be secondary to cervical spine disease or cervical ribs; localisation of swallowed foreign body, or for vague pains in the neck. All neck radiographs performed for trauma were excluded from the control group.
compared with 17 (17%) of the controls. In the goitre group, of the 132 vertebrae in which osteophytes were observed, the fifth cervical vertebra (C5) was most frequently involved, constituting 43.2% (57 vertebrae). This was followed by C4 with 20% (27 vertebrae) and C6 with 18.2% (24 vertebrae). The distribution of osteophytes by vertebrae is illustrated in Fig. 4. The percentage of patients showing osteophytes in each age group is compared in patients with goitre
RESULTS Anterior Marginal Osteophytes Anterior marginal osteophytes (Figs 1, 2, 3) were observed in 60 (37.5%) of the patients with goitre,
Fig. 1 - Lateral neck radiograph of a 45-year-old man. Anterior marginal osteophytes are noted from C4 to C6 with minimal associated disc space reduction. A nodular calcification is noted within the goitre.
26
CLINICAL RADIOLOGY
.&.,
£-
60
2. t4=,
o ~
13
.El 4-, > r
6 z Fig. 2 - Forty-year-old female. Osteophytes are present on C4, 5 and 6. The osteophytes in this patient appear detached.
1~2 3 /., 5 6 7 Cervical vertebral number. Fig. 4 - Histogram illustrating the distribution of marginal osteophytes by vertebrae. A total o f 132 vertebrae were involved. Note that C5 is predominantly affected.
and in controls (Table 1). In only 146 goitre patients and 84 controls was adequate information about patient's age provided. There is overall a significantly higher prevalence of osteophytes in patients with goitre than in controls (Table 2). When broken down into specific age groups (Table 3), 16.7% of goitre patients up to 30 years of age had osteophytes, whereas none of the controls in this age group showed this feature. However, after the age of 50 years, although the prevalence of cervical osteophytes remains higher in goitre patients than in controls, the difference is not statistically significant (Table 3). Although intervertebral disc-space narrowing was frequently observed in association with osteophytes, in most cases marginal osteophytes occurred without disc narrowing. An attempt was made to relate the presence of osteophytes to duration of thyroid swelling, but no correlation was found. Changes in Cervical Curvature Fig. 3 - Thirty-year-old female. Marginal osteophytes are again noted on C4, 5 and 6, although the thyroid is only moderately enlarged.
Straightening or frank reversal of normal cervical lordosis was frequently observed. These features were
CERVICAL SPINE CHANGES IN GOITRE_S
27
Table 1 - Cervical osteophytes in relation to age in patients with goitre and in controls Controls
Goitre patients Age (y ears)
10-20 21-30 31-40 41-50 51-60 O~r60 Grand total
Total no. o f patients
No. with osteophytes
Percentage
No. with o steophy tes
Percentage
Total no. o f con trois
12 30 37 38 20 9
0 7 15 16 13 8
0 23.3 40.5 42.0 65.0 89.0
18 21 21 15 7 2
0 0 5 3 4 2
0 0 23.8 20 57 100
146
39
40.4
84
14
16.7
~
Table 2 - Overall prevalence of osteophytes in patients with goitre and in controls Go#re patients
Controls
Total
59 87
14 70
73 157
146
84
230
No. with osteophytes No. without osteophytes Total Percentage with osteophytes
40.4
16.7
×2 = 13.38 on 1 d.f.;P < 0.001 (d.f. = degrees of freedom).
noted in 47 (29.4%) of the patients with goitre, 38 o f whom had straightening (Figs 5, 6) and nine showed reversal of cervical lordosis (Figs 7, 8). In the control group, only eight patients (8%) showed straightening, but reversal of cervical curvature was not present in any. In several o f the patients with goitre the reversal of curvature was limited only to the vertebrae directly related to the thyroid swelling, i.e. C5 to C7, with the upper cervical vertebrae maintaining a normal alignment (Fig. 7).
DISCUSSION
Except in association with trauma, the cervical spine normally maintains its lordosis, even in the presence of advanced disc degeneration (Hadley, 1964). The apex of the lordosis is formed b y C4 and C5, and the m a x i m u m range o f movement occurs at C5 and C6 (Bowden e t al. 1967). It is therefore not surprising that cervical spondylotic changes occur most frequently at C5 and in the immediately adjoining vertebrae (Hadley, 1964). The distribution o f marginal osteophytes in patients with goitre also conforms to this pattern (Fig. 4). The pressure on the trachea from an enlarged thyroid gland produces varying degrees of discomfort and airway obstruction. It is suggested that part o f the patient's response to the pressure effect o f the goitre is to flex the neck in a reflex attempt to reduce the compression on the trachea This attempt may successfully produce radiologically obvious straightening or fraflk reversal of cervical lordosis or impose such additional stresses on the cervical spine as to predispose to cervical spondylosis, manifested as marginal osteophytes. It is noteworthy that in several cases the reversal of curvature was limited to the
Table 3 - Goitre patients vs. controls: prevalence of osteophytes in specific age groups Age (years)
10-30
Over 50
31-50
Controls
Total
Controls Total
Patients
Controls
No. with osteophytes No. without osteophytes
7 35
0 39
7 74
31 44
8 28
39 72
21
6
8
3
27 11
Total
42
39
81
75
36
111
29
9
38
41.3
22.2
Percentage with osteophytes 16.7
0
X2 = 7.11 on 1 d.f.; P < 0.001
×2 = 3.90 on 1 d.f.; 0.05 > P > 0.02
Total
Patients
Patients
72.4
66.7
×2 = 0.11 on 1 d.f.; P > 0.05 (not significant)
28
CLINICAL RADIOLOGY
Fig. 5 - Thirty-two-year old female, with goitre of 8 years duration. The cervical lordosis is straightened but no osteophytes are present.
Fig. 6 - Fifteen-year-old girl. The cervical lordosis is lost.
cervical spine region w h e r e t h e t h y r o i d mass (and t h e r e f o r e its pressure e f f e c t ) was m a x i m a l (Fig. 7). B o t h marginal o s t e o p h y t e s and even reversal o f cervical lordosis are f r e q u e n t l y o b s e r v e d in illustrations
Fig. 7 - Fifty-year-old female. There is localised reversal of the cervical lordosis at the region of C5 to C7. Note severe sagittal narrowing and posterior displacement of the trachea by the goitre, corresponding to the level of reversal.
Fig. 8 - Lateral neck radiograph in a 13-year-old girl, showing total reversal of the normal cervical curvature. There is a la~g~ retrotracheal extension of the goitre. Note also a noduN calcification within the goitre at the thoracic inlet.
CERVICAL SPINE CHANGES IN GOITRES accompanying publications on goitres, with no comments made about them, e.g. Erazo and Wahner (1966). Reversal of cervical lordosis (arcual kyphosis) is also well recognised as a result of reflex spasm o f paraspinal muscle groups following trivial injury to the neck or upper respiratory tract infection (Penning, 1964). Although the antero-posterior and lateral films performed for the goitre patients are not adequate for assessment of cervical spondylosis, no clinical indication existed to justify obtaining further views. Marginal anterior osteophytes are less likely to produce symptoms, compared with posterior and postero-lateral osteophytes which can produce pressure symptoms on the cervical cord and nerve roots respectively (McRae, 1960). The incidence of cervical spondylosis increases steadily with age and may be as high as 80% in persons over 55 years of age (Brain, 1963). This variation with age is also borne out by the results displayed in Table 1. It is remarkable that of the patients in the control group who did not exceed 30 years of age, none had osteophytes, whereas osteophytes were present in almost 17% of patients with goitre in the same age group (Tables 1,3). After the age of 50 years, the difference in the prevalence of marginal cervical osteophytes ceases to be significantly different
29
between the two groups (Table 3), obviously because after this age the high incidence of degenerative disease becomes the predominant factor. Acknowledgements. I am grateful to Professor O. Ayeni of the Department of Preventive and Social Medicine, University of Ibadan, for his assistance in statistical analysis of the data. I also wish to thank Mr S. C. Alozie for secretarial assistance.
REFERENCES
Bowden, R. E., AbduUah, S. & Gooding, M. R. (1967). Anatomy of the cervical spine membrances, spinal cord, nerve roots and brachial plexus. In Cervical Spondylosis, ed. Brain, L. & Wilkinson, M.~ pp. 54 55. William Heinemann Ltd., London. Brain, L. (1963). Some unsolved problems of cervical spondylosis. British Medical Journal, 1,771-777. Erazo, S. T. & Wahner, H. W. (1966). Roentgenographic diagnosis of thyroid cancer in the presence of endemic goitre. American Journal of R oentgenology , 96,596-603. Hadley, L. A. (1964). Anatomieo-Roentgenographie Studies o f the Spine, pp. 123-124. Charles C. Thomas, Springfield, Illinois. McRae, D. L. (1960). The significance of abnormalities of the cervical spine. American Journal of Roentgenology, 84, 3-25. Penning, L. (1964). Non-pathologic and pathologic relationships between the lower cervical vertebrae. American Journal of Roentgenology, 91, 1036-1050.