title: Radiographic Evaluation of the Reliability of Neck Anatomic Structures as Anterior Cervical Surgical Landmarks.
abstract: BACKGROUND
  Accurate location of the skin incision is helpful to decrease the technical difficulty and save the operative time in anterior cervical spine surgery. Spine surgeons usually use the traditional neck anatomic structures (the hyoid bone, thyroid cartilage, and cricoid cartilage) as landmarks during the surgery. However, the reliability of these landmarks has not been validated in actual practice.
  
  
  OBJECTIVE
  To find out which landmark is the most accurate for identifying the cervical levels in anterior cervical spine surgery.
  
  
  METHODS
  The lateral flexion and extension radiographs of cervical spine in standing position from 30 consecutive patients from January 2015 to February 2015 were obtained. The cervical vertebral bodies from C2 to C7 were divided equally into 2 segments. The cervical segments corresponding to each of the surface landmarks were recorded on the flexion and extension radiographs, respectively, and the displacement of corresponding cervical segments from the flexion to extension radiographs for each landmark was calculated.
  
  
  RESULTS
  Based on the measurements, the main corresponding cervical levels for the mandibular angle were C2 on both of the flexion and extension films, for the hyoid bone were the C3-C4 interspace on flexion film and C3 on extension film, for the thyroid cartilage C5 on both of flexion and extension films, and for the cricoid cartilage C6 on flexion film and C5-C6 interspace on extension film, respectively. The ratios of displacement within 2 segments from flexion to extension were 83.3% (25/30) for mandibular angle, 56.7% (17/30) for hyoid bone, 66.7% (20/30) for thyroid cartilage, and 56.7% (17/30) for cricoid cartilage, respectively. The mean displacement from flexion to extension films were significantly less than 2 cervical segments for the mandibular angle but greater than 2 segments for the other landmarks. Significant differences were found between mandibular angle and the other 3 landmarks for the displacement from flexion to extension.
  
  
  CONCLUSIONS
  The angle of mandible was found to be the most accurate landmark for identifying the cervical level, which corresponded to C2 and C2-C3 disc space. The hyoid bone, thyroid cartilage, and cricoid cartilage were not reliable to predict the cervical levels.
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Jia-Ming
authors.initials: JM
authors.lastname: Liu
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Liu-Xue
authors.initials: LX
authors.lastname: Du
authors.affiliation: Department of Orthopedic Surgery, the 94th Hospital of Chinese People's Liberation Army, Nanchang, P. R. China.
authors.forename: Xu
authors.initials: X
authors.lastname: Xiong
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Xuan-Yin
authors.initials: XY
authors.lastname: Chen
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Yang
authors.initials: Y
authors.lastname: Zhou
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Xin-Hua
authors.initials: XH
authors.lastname: Long
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China.
authors.forename: Shan-Hu
authors.initials: SH
authors.lastname: Huang
authors.affiliation: Department of Orthopedic Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, P. R. China. Electronic address: liuzhiliyfy@163.com.
authors.forename: Zhi-Li
authors.initials: ZL
authors.lastname: Liu
mesh_terms: D000328:Adult; D059925:Anatomic Landmarks / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D002574:Cervical Vertebrae / Q000601:surgery*; D003413:Cricoid Cartilage / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D006928:Hyoid Bone / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D008297:Male; D009333:Neck / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D011859:Radiography; D015203:Reproducibility of Results; D013957:Thyroid Cartilage / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D055815:Young Adult
keywords: Cervical; Landmarks; Mandibular angle; Spine