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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Morphological and Morphometric Variations in Foramen Transversarium: A Cross-sectional Study in Dried Cervical Vertebrae of Western Odisha Origin
Correspondence Address :
Dr. Sarita Behera,
Assistant Professor, Department of Anatomy, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Sambalpur-768017, Odisha, India.
E-mail: drsaritabehera81@gmail.com
Introduction: Foramen transversarium refers to bilateral foramina found lateral to the vertebral body in the transverse process of the cervical vertebrae. Many variations are observed in these foramina which may lead to vertebrobasilar insufficiency, labyrinthine or hearing disturbances along with neurological symptoms due to compression or tortuosity of vertebral artery as it passes through the foramen.
Aim: To study the morphological and morphometric variations of the foramen transversarium in cervical vertebrae.
Materials and Methods: This cross-sectional study was conducted in Department of Anatomy, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India, from June 2022 to August 2022. A total of 367 human cervical vertebrae were procured from the anthropology section of Department of Anatomy. Vertebrae with any damage to foramen transversarium were discarded. Each vertebra was observed for shape, size, symmetry, number of foramen transversarium and osteophytic encroachment. Distance of foramen transversarium from the medial margin of uncinate process was measured bilaterally in C3 to C7 vertebrae. Data collected was tabulated and analysed by Microsoft Excel software 2019.
Results: Mean anteroposterior diameter and transverse diameter in left-side were 5.45 mm and 5.42 mm, respectively and in right-side the measurements were 5.29 mm and 5.23 mm, respectively. Double foramen transversarium was observed in 40 (10.9%) vertebrae. Among them 18 (4.9%) were bilateral and 22 (6.0%) were unilateral. In 2 (0.54%) vertebrae there was triplication of foramen transversarium. In 34 vertebrae (9.26%) there was incomplete duplication of which 9 (2.45%) were bilateral and 25 (6.81%) were unilateral. Six different shapes of foramen transversarium were observed out of which round shape (62.1%) was the most common finding. In 261 (71.1%) of vertebrae the main foramen transversarium was symmetrical in both sides but in 106 (28.9%) it was asymmetrical. Osteophytic encroachment was found in 14 (3.81%) vertebrae. The mean distance of the foramen from medial margin of uncinate process was 5.32 mm on the left and 5.42 mm on the right-side.
Conclusion: The morphological data like very narrow foramina and such a high number of accessory foramina produced through the present study definitely points towards the variations of vertebral vessels.
Foramina, Morphometry, Osteophyte, Spine, Vertebrobasilar
Foramen transversarium refers to bilateral foramina found lateral to the vertebral body in the transverse process of the cervical vertebrae. It is ventrally by ventral bar and dorsally by dorsal bar. Each of the bars end in a tubercle laterally which are connected by intertubercular or costal lamella that forms the lateral boundary of the foramen. Developmentally, it is formed between vestigeal costal element anteriorly and true transverse process posteriorly (1).
These foramina are found only in cervical vertebrae and serve as a good way to identify them. Vertebral artery, vertebral vein and sympathetic plexus arising from inferior cervical ganglion pass through these foramina. Vertebral vein passes through all the seven foramina transversaria whereas the vertebral artery does not pass through the foramen transversarium of the seventh cervical vertebra as it mostly enters at the 6th cervical vertebra level for its vertebral course. Ideally, each cervical vertebra should have two foramen transversaria. But many variations are observed in these foramina. Congenital absence of the transverse foramen and osteophyte formation are reported to be one of the causative factors for vertebrobasilar insufficiency caused by rotation of the head. Vertebrobasilar insufficiency is characterised by headache, migraine and fainting attack. Also, inner labyrinthine or hearing disturbances along with neurological symptoms (2),(3).
It has been reported that vertebral vessels are responsible for formation of foramen transversarium. So variations in the course of the vertebral vessels may be one of the causative factors for variations in foramen transversarium. It is also noted that tortousity of vertebral artery may cause bone erosion or obstruct the complete formation of the foramen transversarium (4). Now-a-days transpedicular screw fixation of cervical spine is preferred surgery for instability due to trauma, tuberculosis, neoplasia or degenerative conditions and screw is placed just medial to foramen transversarium, so the vertebral artery is at risk of injury (5).
As per literature, most of the earlier studies have focused either on morphology or morphometry of foramen transversarium in different populations (6),(7),(8),(9),(10). Study by Nayak G et al., which included the bones of eastern part of Odisha also describes only about the incidence of accessory foramen transversarium (11), they have not studied the morphometric details. Hence, the present study was undertaken to study both the morphological and morphometric variations of foramen transversarium in dry bones of western Odisha population in a comprehensive way, which will definitely be helpful for the neuro and orthopaedic surgeons and the radiologists of this part of India to increase the effectiveness of the surgical and diagnostic procedures and decrease the complications related to injury of vertebral artery.
This cross-sectional study was conducted from June 2022 to August 2022 in Department of Anatomy, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India. Study was commenced after obtaining approval from the Institutional Ethics Committee (IEC) (IEC no 009-2022/I-F-O/43/Dt.17-05-2022).
Inclusion criteria: Both typical and atypical cervical vertebrae were included in the study.
Exclusion criteria: Vertebrae with damaged foramen transversarium were excluded from the study.
Data collection: A total of 367 human cervical vertebrae of unknown age and sex, were procured from the anthropology section of Department of Anatomy, VIMSAR, Burla. Each vertebra was observed for shape, size, symmetry, osteophytic encroachment and number of foramen transversarium. In vertebrae having accessory foramen transversarium the larger foramen was taken as the main foramen and smaller one as accessory foramen.
The shapes of the foramina were classified into six categories using the criteria by Ambali MP and Jadhav SD with little modifications (12).
• Type-1 round,
• Type-2 elliptical with main diameter (length) anteroposterior,
• Type-3 elliptical with main diameter transverse (breadth),
• Type-4 elliptical with main diameter oblique, from right to left,
• Type-5 elliptical with main diameter oblique from left to right,
• Type-6 as irregular.
The widest anteroposterior and transverse diameters of main transverse foramina taken on the inner side were measured bilaterally using digital Vernier caliper (Table/Fig 1). In C3-C7 vertebrae distance of medial margin of foramen transversarium from the medial margin of uncinate process was measured.
Statistical Analysis
Data collected was tabulated and analysed by Microsoft Excel software 2019. The range, mean and standard deviation of all the measurements like anteroposterior diameter, transverse diameter, mean diameter and distance of medial margin of the foramen transversarium from the uncinate process were calculated. The scatter chart for the mean diameters of foramen transversarium of the right and left-side was plotted.
Mean anteroposterior diameter and transverse diameter in left-side were 5.45±0.81 mm and 5.42±0.79 mm, respectively and in right-side the measurements were 5.29±0.81 mm and 5.23±0.75 mm, respectively. The mean distance of the medial margin of the foramen from the uncinate process was 5.32±1.18 mm on the left and 5.42±1.33 mm on the right-side (Table/Fig 2). Mean diameter of transverse foramen of individual vertebra showed wide range of variation ranging from 1.17-6.95 mm in the right-side and 1.05-6.95 mm in left-side (Table/Fig 3),(Table/Fig 4).
Double foramen transversarium was observed in 40 (10.9%) vertebrae. Among these 18 (4.9%) was bilateral and 22 (6.0%) was unilateral. In 2 (0.54%) vertebrae there was triplication of foramen transversarium. In 261 (71.1%) of vertebrae the foramen transversarium was symmetrical in both sides but in 106 (28.9%) it was asymmetrical. In 34 vertebrae (9.26%) there was incomplete duplication out of which 9 (2.45%) was bilateral and 25 (6.81%) was unilateral. Osteophytic encroachment was found in 14 (3.81%) vertebrae (Table/Fig 5),(Table/Fig 6),(Table/Fig 7). Six different shapes of foramen transversarium were observed. Type-1 or round shape was the most common finding bilaterally (Table/Fig 8),(Table/Fig 9).
Anatomically foramen transversarium has been described to be divided by fibrous or bony ridge, separating artery and vein, the smaller posterior part that encloses a branch of vertebral nerve and vein is called accessory foramen transversarium. Separate area in the form of complete accessory foramen transversarium for vertebral vein and nerve offers limited space. Any irritation or inflammation of nerve causes pressure effect on nerve and vein as well. Such duplication of foramen transversarium or accessory foramen transversarium may be suggestive of duplication of vertebral artery or separate area for vertebral vein and nerve. Awareness of such variation and its incidence is clinically important for spine surgeons to prevent intraoperative complications by damaging vertebral artery and vein (4).
Duplication of foramen transversarium may be associated with developmental anomalies of vertebral artery, such as duplication and fenestration or due to abnormality during formation of vertebra itself. Vertebral arteries are formed by fusion of the longitudinal anastomosis, connecting the cervical intersegmental arteries. The intersegmental arteries regress during the embryonal development except the 7th intersegmental artery, which forms the proximal portion of the subclavian artery and initial part of the vertebral artery. Persistence of a portion of primitive dorsal aorta with two intersegmental arteries results in duplication of vertebral artery. This may lead to accessory foramen transversarium (2).
Accessory vertebral arteries if present may potentially be protective against ischaemic attacks to the brain by providing collateral blood flow to the basilar artery. However, fenestrated vertebral arteries have been demonstrated histologically to be weak with irregular elastic fibres in the vessel wall. There may be a higher risk of thrombus development and embolisation leading to a severe transient ischaemic attack in people with fenestrated or duplicated vertebral arteries (13).
During development of vertebra, double rib bone element may fuse to the original transverse process resulting in unusual number of foramen transversarium (12). Study by Gupta M and Agarwal S on 319 foramen transversarium of 161 cervical vertebrae at Lady Hardinge Medical College, Delhi in 2019 found accessory foramen transversarium in 26.09% where majority were at C6 level and nil at C1 and C2 level (14). Similar report was made by Patil NP et al., in a study on 175 cervical vertebrae at Ambjogai, Maharashtra in 2014 that the accessory foramen transversarium was more common in lower cervical vertebrae (15). Present study found it to be 54.7% in C6 and nil in C1 and C2.
Vasuki AKM et al., in their study on 300 cervical vertebrae at Coimbatore in 2018 found triple foramen in right-side in one (0.003%) vertebra (4). In the present study, in two (0.54%) vertebrae there was triplication of foramen transversarium.
Anatomical variations in the vertebral artery, embryological factors and functional conditions may play an important role in the formation of incomplete transverse foramen. It was noted that the tortousity of vertebral artery may cause bony erosion or obstruct the complete formation of foramen transversarium (4),(16). Vasuki AKM et al., found unilateral incomplete duplication in 3% and bilateral incomplete duplication in 2% out of 125 vertebrae showing variation (4). Shah ST et al., in their study on 210 vertebrae at Gujarat in 2014 found unilateral incomplete duplication in 3.8% (6). In the present study, in 34 vertebrae (9.26%) there was incomplete duplication out of which 9 (2.45%) was bilateral and 25 (6.81%) was unilateral.
Size of transverse foramen is directly proportional to the calibre of vertebral artery. Size of transverse foramen carries clinical significance as vertebrobasilar insufficiency may be seen in case of narrowing of foramen transversarium. During the development of bone, new layers are added to the pre-existing surfaces. Reduced foramen area of some cervical vertebrae may be attributed to periosteal growth at foramen margins to fit around their neurovascular and other contents (4).
Bow hunter’s stroke is a symptomatic vertebrobasilar insufficiency caused by stenosis or occlusion of the vertebral artery with head rotation (7). Ambali MP and Jadhav SD in their study on 163 cervical vertebrae at Maharashtra in 2016 observed the average diameter of the foramen transversarium on the right-side to be 5.46 mm and on the left to be 5.80 mm (12). In present study, the largest diameter was 7.30 mm and smallest was 1 mm. Previous studies had shown that the two vertebral arteries are not equal in size in 75% of people and of these,10% have quite narrow vertebral arteries in right-side (7). Agrawal D et al., conducted a study on 160 cervical vertebrae of eastern Odisha in 2012 and reported asymmetrical foramen transversarium only in one specimen in typical vertebrae (17). Ambali MP and Jadhav SD, observed symmetrical foramen transversarium in 91 (55.82%) out of 163 vertebrae (12). In the present study asymmetrical foramen transversarium were found in 106 out of 367 vertebrae (28.9%).
As per literature, osteophytes are more common along the medial or lateral margins of the foramen transversarium reducing the transverse diameter, type 2 where the main diameter is along the anteroposterior direction is most likely to be involved in compression of the vertebral artery whereas type 3 where main diameter is along the transverse axis is at minimal risk [18,19]. Ambali MP and Jadhav SD, found seven different shapes of foramen transversarium. Out of them oval and tilted to right was the most common shape (44.78%) (12). Vasuki AKM et al., found five different shapes out of which Type-1 or round shape was the most frequent (43.6%) (4). Patra A et al., in their study on 200 cervical vertebrae of south central Asian cadavers in 2022 observed type 1 or round shape (27.13%) to be the most common in right-side and type-4 or elliptical with main diameter from right to left (27.63) in left-side (18). In present study, six different shapes were observed and round shape was the most common (62.1%) in both sides. Most of the studies describe unilateral accessory foramen to be more common than bilateral which was consistent with present study (Table/Fig 10) (2),(4),(6),(7),(8),(9),(10),(11),(12),(20),(21),(22),(23),(24),(25),(26).
Ambali MP and Jadhav SD, found bony spicules in 12 (7.36%) out of 163 vertebrae (12). Sangari SK et al., observed osteophytic encroachment in 21.3% of vertebrae studied (7). Patra A et al., observed osteophytes in 21.3% (18). In present study, authors observed osteophytic encroachment in 14 (3.81%) out of 367 vertebrae. The osteophytes encroaching the transverse foramina are potential sites of trauma to the vertebral artery which may also compress it resulting in its narrowing leading to vertebrobasilar insufficiency.
To avoid vertebral artery injury during anterior cervical disc surgery, the medial margin of the uncovertebral joint may be the safe landmark. The distance of foramen transversarium from uncinate process found in the present study which was consistent with findings of previous studies (Table/Fig 11) (7),(14),(16),(18),(23). The risk of vertebral artery laceration may be increased, especially when osteophytes are removed from uncinate process by lateral decompression. So, it is better to perform this procedure under direct visualisation with opening of the anterior walls of the transverse foramen and retracting the vertebral artery laterally (7).
Limitation(s)
As the study was done in dried vertebrae collected from the anthropology section, age and sex correlation could not be done.
Finding of extremely narrow foramen transversarium as small as 1 mm in diameter and accessory foramina in such a good number of vertebrae in the present study raises questions about the integrity of the contained structures. This factor leading to vertebral artery compression should not be ignored while searching for the differential diagnosis of complaints like headache, migraine and fainting attacks. So, the results generated through this osteological study should be correlated by undertaking radiological studies to confirm the variations of the vertebral vessels. Further, though the other morphometric details of foramen transversarium have been studied in different populations of India, the distance of uncinate process from its medial margin generated through this study will be first of its kind.
DOI: 10.7860/JCDR/2023/63927.18035
Date of Submission: Mar 09, 2023
Date of Peer Review: Apr 04, 2023
Date of Acceptance: May 23, 2023
Date of Publishing: Jun 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No
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