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A Novel Anatomic Landmark to Assess Adequate Decompression in Anterior Cervical Spine Surgery

The Posterior Endplate Valley (PEV)

Aleem, Ilyas S. MD, MSc, FRCSC*,†; Alder, Jason MD; Popper, Joseph MD; Freedman, Brett MD; Nassr, Ahmad MD; Bydon, Mohamad MD§; Yaszemski, Michael J. MD, PhD; Currier, Bradford L. MD

doi: 10.1097/BSD.0000000000000877

Study Design: A retrospective study.

Objectives: (1) To assess the reliability of using the posterior endplate valley (PEV) to predict the cranial-caudal location of the cervical pedicle intraoperatively; (2) to assess the impact of age on the cervical PEV-pedicle relationship, interpedicular distance, and foraminal height.

Summary of Background Data: The cervical pedicle, which is the anatomic landmark defining the boundaries of the foramen, is hidden from view intraoperatively in the anterior cervical approach, potentially leading to incomplete foraminal decompression. An intraoperative landmark which heralds the location of the pedicle and therefore can be relied upon as a guide for decompression has not been previously described.

Methods: We retrospectively reviewed cervical computed tomography images of younger (<50 y) and older (>50 y) patients. Using the coronal reconstructed image taken at the posterior margin of the vertebral body, we constructed a line between the superior aspect of the pedicles and measured the distance from this line to the PEV. Interpedicular distance and foraminal height were also measured.

Results: One hundred patients were included in the final analysis. The mean distance (mm) from the pedicular line to the PEV from C3 to C7 respectively was 1.0±0.99, 0.01±0.76, 0.09±0.70, 0.20±0.71, and 0.27±0.79. No significant difference between young and elderly patients was noted (P<0.05). Intervertebral foraminal size was significantly greater in younger compared with elderly patients at all levels except C2–C3. The mean interpedicular distance was 23.05±1.76 mm.

Conclusions: This study demonstrates, for the first time, that the PEV is an accurate surgical landmark that is consistently at most 1 mm from the superior aspect of the cervical pedicle in the subaxial spine. Furthermore, this study demonstrated that foraminal height was significantly larger in younger compared with elderly patients at all cervical levels below C3.

Level of Evidence: Level 3.

Departments of *Orthopaedic Surgery

Neurosurgery, University of Michigan, Ann Arbor, MI

Departments of Orthopaedic Surgery

§Neurosurgery, Mayo Clinic, Rochester, MN

The authors declare no conflict of interest.

Reprints: Ilyas S. Aleem, MD, MSc, FRCSC, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (e-mail:

Received July 9, 2018

Accepted April 19, 2019

© 2019 by Lippincott Williams & Wilkins, Inc.