Saudi Journal of Sports Medicine

: 2018  |  Volume : 18  |  Issue : 2  |  Page : 59--62

Reliability and validity of X-ray findings in cervical dysfunction: A brief review

Navjeet Kaur, Narkeesh Arumugam, Shefali Gambhir 
 Department of Physiotherapy, Punjabi University, Patiala, Punjab, India

Correspondence Address:
Narkeesh Arumugam
Department of Physiotherapy, Punjabi University, Patiala, Punjab


Background: Cervical spine dysfunction is a common and broad condition represented by pain, limitation in the range of physiological movements, tenderness, and stiffness besides symptoms and information gathered from the patient history in decision-making, and the diagnostic and prognostic accuracy can be done using magnetic resonance imaging (MRI), computed tomography (CT) scan, myelogram, discography, single photon emission CT, and X-ray. Aims and Objectives: The aim of the present study was to find the X-ray findings in cervical dysfunction and assess its psychometric properties through analyzing various articles. Methodology: Various articles from following databases such as Science Direct, Springer Link, EMBASE, PubMed, and Cochrane were gathered using terms such as “Cervical Dysfunction,” “Cervical Canal Diameter,” and “Radiological Findings.” A total of 12 articles based on the PICO format were included in the study, and based on their findings, a review was made. Discussion: MRI is the first line of choice to diagnose cervical disorders, but as we know, our India is developing country, so we need the cheap and easy diagnostic tool to assess. The reliability of the Torg ratio/Pavlov ratio, sagittal dimension of cervical canal, stress lines of the cervical spine, and cervical angle are different methods used to diagnose the cervical dysfunction using anteroposterior and lateral view of X-ray. Conclusion: Radiographic measurements can be used to evaluate cervical spondylosis and cervical stenosis but cannot evaluate neurological outcomes.

How to cite this article:
Kaur N, Arumugam N, Gambhir S. Reliability and validity of X-ray findings in cervical dysfunction: A brief review.Saudi J Sports Med 2018;18:59-62

How to cite this URL:
Kaur N, Arumugam N, Gambhir S. Reliability and validity of X-ray findings in cervical dysfunction: A brief review. Saudi J Sports Med [serial online] 2018 [cited 2019 Jan 24 ];18:59-62
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Full Text


Cervical spine dysfunction is a common and broad condition represented by pain, limitation in the range of physiological movements, tenderness, and stiffness.[1] It affects both males and females mostly in age group of 12–50 years. The incidence of neck pain in the population has been reported to be as high as 67% experiencing it from the last 6 months.[2] Degenerative disc disease occurs in more than 90% of adults over the age of 5 years and almost 100% by 70 years.[3]

Cervical dysfunction occurs due to the abnormal forces acting on spinal column and cord during movement which results in the neck pain.[4] It occurs due to disc herniation, annular protrusion, worsening degenerative changes, and increased ligamentous laxity.[5] Other mechanical factors that causes dysfunction are congenital canal stenosis, disc herniation, degenerative osteophyte growth, hypertrophy of ligamentum flavum, and calcification of posterior longitudinal ligament.[4] Studies show that persisting problems occur with many activities such as driving a car, turning the head and working on a computer and reduced ability in work concentration.[6]

Magnetic resonance imaging (MRI) is the first line of choice to diagnose cervical disorders. As the study is to prove that X-ray as valid and reliable tool. Yu et al. 2015 proved X-ray as a quantitative diagnostic tool to evaluate cervical spondylosis in China.[7] Salam et al. 2010 also evaluated the utility of cervical spine radiography in determining cervical spondylitis.[8] Malzac et al. in 2002 observed that value of Torg ratio 0.80 or less than it indicates spinal stenosis.[9]

The present review intends to collect evidences to support X-ray as a diagnostic tool for evaluating cervical dysfunction.


Relevant articles were studied from Science Direct, Springer Link, EMBASE, PubMed and Cochrane, and Inclusion criteria are set by PICO to define the research problem and the following queries were used: Torg ratio/Pavlov ratio, sagittal dimension of X-ray, stress lines of cervical spine, and cervical angle.


A total of 12 articles were taken and studies retrieved from the various articles in review study are tabulated as shown in [Table 1] describing about author, sample size, title/nature, and findings of studies.{Table 1}


Radiographic evaluation for cervical spine is the first diagnostic tool to evaluate inpatients with neck and limb symptoms; but now, MRI is becoming the better imaging modality to diagnose cervical radiculopathy. Now, most of studies use radiography to evaluate cervical spondylosis, degenerative disk disease, or posttraumatic malalignment.[20] Degenerative changes in disc spaces can also lead to changes in surrounding soft tissues.[13] Mantyselka showed that metabolic syndrome can also be the one of the causes of musculoskeletal pain due to lack of physical activity.[21] Faisal also showed the significant reduction in handgrip strength on the affected side of cervical radiculopathy.[3] Tierney proved that Space Available for the Cord (SAC) measures are more reliable than Torg ratio in determining canal stenosis.[18] Wong proved that radiography alone cannot be used to predict the level of neurological injury.[17] Ofiram proves the radiological measurements to be the most accurate tool to measure cervical degenerative in cervical spondylosis.[13] Morishita et al. concluded that individuals with sagittal canal diameter <13 mm may be at an increased risk for future development of upper cervical stenosis following the lower segments.[11] Yu et al. proved X-ray as diagnostic tool to measure cervical spondylosis.[7],[22] Kasai proved that cervical spinal stenosis mostly occurs in the patients with smaller intercanthal distance.[14] Zhang et al. proved that Torg ratio, sagittal diameter, and transverse diameter can be used as geometric parameters to measure cervical spine in future.[10]


Literature review of the present study concludes that radiographic measurements can be used to evaluate cervical spondylosis and cervical stenosis but cannot evaluate neurological outcomes. Hence, X-ray should be used over MRI in diagnosing cervical dysfunction as it is easy and cheapest tool.


The authors are very thankful to Mr. Asir John Samuel, BSc (Psychology), BPT, MPT (Neurosciences and Paediatric neurology), DYScEd, (PhD), Associate Professor, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar University, Mullana, India, for providing technical support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Weber P, Corrêa EC, Ferreira Fdos S, Soares JC, Bolzan Gde P, Silva AM, et al. Cervical spine dysfunction signs and symptoms in individuals with temporomandibular disorder. J Soc Bras Fonoaudiol 2012;24:134-9.
2Todd AG. Cervical spine: Degenerative conditions. Curr Rev Musculoskelet Med 2011;4:168-74.
3Faisal CK, Mathew N, Mathias L, Ajith S. Grip strength and hand function changes in unilateral cervical radiculopathy. Int J Curr Res Rev 2012;4:82-90.
4Mullin J, Shedid D, Benzel E. Overview of cervical spondylosis pathophysiology and biomechanics. World Spinal Column J 2011;2:89-97.
5Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. Clin Orthop Trauma 2014;5:221-6.
6Singh B, Singh S. Intervention approaches in management of neck pain among computer users. Int J Ther Rehabil Res 2016;5:19-24.
7Yu X, Liu M, Meng L, Xiang L. Classifying cervical spondylosis based on X-ray quantitative diagnosis. Neurocomputing 2015;165:222-7. Available from: [Last accessed on 2017 Oct 23].
8Salam A, Ahmed MU, Kohistani TA. Radiographic evaluation of cervical spine. Rawal Medical Journal 2010;35:152–5.
9Malzac A, Pessoa TE, Filho B. Morphometry of the spinal canal at cervical region in asymptomatic military young men. Acta Ortop Bras 2002;10:40-51.
10Zhang L, Chen HB, Wang Y, Zhang LY, Liu JC, Wang ZG, et al. Cervical spinal canal narrowing and cervical neurological injuries. Chin J Traumatol 2012;15:36-41.
11Morishita Y, Naito M, Wang JC. Cervical spinal canal stenosis: The differences between stenosis at the lower cervical and multiple segment levels. Int Orthop 2011;35:1517-22.
12Song KJ, Choi BW, Kim SJ, Kim GH, Kim YS, Song JH, et al. The relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury: An analysis using pavlov's ratio, spinal cord area, and spinal canal area. Clin Orthop Surg 2009;1:11-8.
13Ofiram E, Garvey TA, Schwender JD, Denis F, Perra JH, Transfeldt EE, et al. Cervical degenerative index: A new quantitative radiographic scoring system for cervical spondylosis with interobserver and intraobserver reliability testing. J Orthop Traumatol 2009;10:21-6.
14Kasai Y, Akeda K, Uchida A. Physical characteristics of patients with developmental cervical spinal canal stenosis. Eur Spine J 2007;16:901-3.
15Athiviraham A, Yen D, Scott C, Soboleski D. Clinical correlation of radiological spinal stenosis after standardization for vertebral body size. Clin Radiol 2007;62:776-80.
16Lee MJ, Cassinelli EH, Riew KD. Prevalence of cervical spine stenosis. Anatomic study in cadavers. J Bone Joint Surg Am 2007;89:376-80.
17Wong TM, Leung HB, Wong WC. Correlation between magnetic resonance imaging and radiographic measurement of cervical spine in cervical myelopathic patients. J Orthop Surg (Hong Kong) 2004;12:239-42.
18Tierney RT, Maldjian C, Mattacola CG, Straub SJ, Sitler MR. Cervical spine stenosis measures in normal subjects. J Athl Train 2002;37:190-3.
19Blackley HR, Plank LD, Robertson PA. Determining the sagittal dimensions of the canal of the cervical spine. The reliability of ratios of anatomical measurements. J Bone Joint Surg Br 1999;81:110-2.
20Daffner RH. Radiologic evaluation of chronic neck pain. Am Fam Physician 2010;82:959-64.
21Mäntyselkä P, Kautiainen H, Vanhala M. Prevalence of neck pain in subjects with metabolic syndrome – A cross-sectional population-based study. BMC Musculoskelet Disord 2010;11:171.
22Yu X, Xiang L. Classifying cervical spondylosis based on fuzzy calculation. Abstract and Applied Analysis 2014; 182956.