Surgical and Radiologic Anatomy (2021) 43:889–907

https://doi.org/10.1007/s00276-021-02690-0

ORIGINAL ARTICLE

Basivertebral foramina of true vertebrae: morphometry, topography

and clinical considerations
Maria Tzika1 · George K. Paraskevas1 · Maria Piagkou2 · Apostolos K. Papatolios1 · Konstantinos Natsis1

Received: 9 July 2020 / Accepted: 18 January 2021 / Published online: 17 February 2021
© The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature 2021

Abstract
Purpose Basivertebral foramina (BVF) are openings of the posterior wall of vertebral body (VB) that lead to basiverte-
bral canals (BVC), where homonymous neurovascular bundle courses. BVF and BVC are implicated with spinal fractures,
vertebral augmentation and basivertebral nerve radiofrequency ablation. Despite their essential clinical impact, knowledge
of BVF precise anatomy is scarce. The current study describes in detail the BVF typical morphological and topographical
anatomy, morphometry and variants.
Methods In total, 1561 dried true vertebrae of 70 Greek spines of known gender and age were examined. BVF number, loca-
tion, shape and size (in foramina > 1 mm), BVF distance from VB rims and pedicles, as well as VB morphometry (diameters,
heights and distance between pedicles) were studied. Ten spines were re-examined by computed tomography and BVC depth
and shape were recorded. Correlations and differences were statistically analyzed.
Results C1 lack BVF (3.4%). One BVF was found in 45.1%, two in 36.9%, three in 3.8% and four BVF in 0.6%. Multiple
small (< 1 mm) foramina were observed in 10.1%. Asymmetry was detected in 12.3%. ­C2 and ­T10–L1 presented typical pat-
tern, whereas C­ 3 and T
­ 2 had the greatest variability. BVF were significantly closer to the upper rim in C
­ 2 and T
­ 10–L4 and to
the lower rim in ­C7–T4, ­T6–T8 and ­L5. The mean BVC depth was 12–21.8% of the VB anteroposterior diameter.
Conclusion BVF number, shape, size and topography are described, in detail, per vertebral level. The provided morphological
classification and the created cumulative BVF topographic graphs should assist in clinical practice and surgery.

Keywords Basivertebral · Foramina · Venous channels · Vertebral body fractures · Cement leakage

Introduction basivertebral veins and BVF [5]. Additionally, VB and

Basivertebral foramina (BVF) are nutrient foramina of the
vertebrae, located at the posterior wall of vertebral bodies
(VB). The BVF lead to the homonymous canal, through
which the basivertebral neurovascular bundle courses. The
basivertebral vessels and nerve are distributed throughout
the VB, providing blood supply and receiving pain sig-
nals. Due to the valveless nature of the internal vertebral
venous system, retrograde blood flow has been connected
with VB metastatic disease and infection spread, through
* Maria Tzika
tzik.maria@gmail.com
1
Department of Anatomy and Surgical Anatomy, School
of Medicine, Faculty of Health Sciences, Aristotle University
of Thessaloniki, P.O. Box 300, 54124 Thessaloniki, Greece
2
Department of Anatomy, Faculty of Medicine, National
and Kapodistrian University of Athens, Athens, Greece
regional cord common blood supply through segmental
arteries is significant for diagnosis of spinal cord ischemia
[5]. The basivertebral nerve is considered to be involved
occasionally in vertebrogenic chronic low back pain, being
a potential key-target for treatment [2]. BVF and homony-
mous canals are implicated in pathophysiology, diagnosis
and evolution of burst and VB compression fractures, as well
as in complications during vertebral cement augmentation
techniques, such as vertebroplasty, kyphoplasty and cement
augmented spine instrumentation and fixation [1, 3, 11–14,
27, 30, 33, 39].
Although BVF are well-known traits, only a few studies
have been published about their morphology and topogra-
phy [22–24, 30]. Thus, the current study aimed to describe
the detailed anatomy and topography of BVF of true dried
vertebrae in a Greek adult population and to record the
variability of BVF morphology and distribution, as well as

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890 Surgical and Radiologic Anatomy (2021) 43:889–907

differences among spinal sections, vertebral levels, gender
and age groups.
Materials and methods
Seventy Greek dried spines, derived from the osteologi-
cal collection of the Department of Anatomy and Surgical
Anatomy, in Aristotle University of Thessaloniki, were ran-
domly included in the current study. Spines with less than
20 true vertebrae, of unknown gender and age at death, as
well as those with pathologic or postmortem VB alterations
were excluded. In total, 1561 true vertebrae were studied
[mean age at death 67 years (range 34–93) and 50.1% of
female origin]. Vertebrae were classified in three age
groups: < 55 years, 55–75 years and ≥ 75 years to better
examine the age impact on studied variables. Demographic
characteristics are summarized in Table 1. Vertebral arches
were resected at the laminae in cervical vertebrae and at
the pedicles in thoracic and lumbar vertebrae, to reveal VB
posterior aspect. All measurements were performed using
the Absolute Mitutoyo digital caliper (0.01 mm accuracy).
In ­C2–L5 vertebrae, the VB anteroposterior and latero-
lateral diameters, the midline anterior and posterior height
and the distance between pedicles from the nearest point
of origin were measured, aiming to detect any possible
correlation of the vertebral morphometry to BVF anat-
omy (Fig. 1). In C
­ 2 vertebrae, the odontoid process height
was additionally measured, at the posterior aspect. In ­C1
vertebrae, the BVF existence at the middle of the poste-
rior aspect of the anterior arch was examined. The BVF
number, shape (round, oval, fissure-like, heart-like and
irregular) and location of the foramina greater than 1 mm
in diameter were noted. BVF vertical and horizontal diam-
eters were measured. BVF topography was investigated
after calculating the minimum distances from the VB
upper rim to the BVF closest point, as well as the distance
from the VB lower rim to the closest BVF. The distance
between the vertical line of the pedicle origin and the BVF
closest point was also measured in each side (Fig. 2a). For
further understanding the BVF topography, the relative

Table 1  Demographic Vertebrae Age Groups among the genders

characteristics of the studied
dried vertebrae, T-total, < 55 years 55–75 years ≥ 75 years TOTAL
F-female, M-male
T F M T F M T F M

C1 13 8 5 23 10 13 17 5 12 53
C2 17 11 6 22 10 12 15 7 8 54
C3 16 9 7 19 9 10 17 8 9 52
C4 12 7 5 25 11 14 23 11 12 60
C5 14 10 4 23 9 14 24 12 12 61
C6 17 12 5 23 11 12 20 9 11 60
C7 18 12 6 26 11 15 23 11 12 67
T1 19 12 7 23 9 14 25 12 13 67
T2 19 12 7 25 10 15 24 11 13 68
T3 19 12 7 26 11 15 25 12 13 70
T4 18 12 6 26 11 15 25 12 13 69
T5 18 12 6 25 10 15 25 12 13 68
T6 18 11 7 26 11 15 25 12 13 69
T7 19 12 7 25 11 14 23 12 11 67
T8 19 12 7 25 11 14 24 12 12 68
T9 19 12 7 25 10 15 25 12 13 69
T10 18 11 7 26 11 15 25 12 13 69
T11 15 11 4 26 11 15 25 12 13 66
T12 17 11 6 25 11 14 24 12 12 66
L1 19 12 7 26 11 15 25 12 13 70
L2 18 12 6 26 11 15 25 12 13 69
L3 17 12 5 26 11 15 25 12 13 68
L4 18 11 7 24 9 15 23 11 12 65
L5 18 11 7 24 10 14 24 12 12 66
Total 267 148 250 340 265 291 1561

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Surgical and Radiologic Anatomy (2021) 43:889–907
Fig. 1  a Superior, b lateral and c posterior aspects of a typical vertebral body. Anteroposterior (AP) and laterolateral (LL) diameters, anterior
(AH) and posterior (PH) height and distance between pedicles (P)
Fig. 2  Basivertebral foramina (BVF) topography. a The distance
between the upper rim of the vertebral body and the BVF closest to it
(U), the distance between the lower rim and the BVF closest to it (Lo)
and the distances between left and right pedicle line and the BVF
position of BVF was calculated. In specific, the distances
between BVF and the left pedicle were calculated as per-
centages of the distance between pedicles, while the dis-
tances between BVF and VB lower rim as percentages
of the total posterior height (Fig. 2b). Additionally, the
rectangular area including BVF was calculated in ­mm2 and
as percentage of the posterior aspect surface area (defined
as posterior height x distance between pedicles) (Fig. 2c).
In order to visualize the BVF distribution of different
vertebrae of the same level, a novelty visualization system
is introduced. For descriptive purposes, topographic graphs
were constructed for each vertebral level, depicting all found
BVF area cases for the vertebral level. Created graphs are
characterized as cumulative topographic graphs, as they
provide details about BVF area mapping. The relative BVF
position for each vertebra was processed with RStudio 3.5.2
software, which is an integrated development environment
for the programming language R. The BVF area for each ver-
tebra is depicted as a transparent rectangle. With the addi-
tion of all cases in the graph, the resulted area with compact
color represents the sum of BVF area distribution for the
vertebral level. In these graphs, the vertical to horizontal
axes ratio is the true ratio of the mean posterior height to
the mean distance between pedicles, respectively, for each
vertebral level (Fig. 3).
891
closest to them (L and R, respectively). b In this example, BVF were
found in 26–68% in the horizontal and 53–58% in the vertical axis. c
The area including BVF (stripped rectangle) was defined and calcu-
lated as percentage of the total posterior aspect area (gray rectangle)
Imaging of a part of the sample
Ten spines (14.28%) were randomly selected to be examined
by computed tomography (CT) scan and this sample was
subdivided into two age groups (< 65 and ≥ 65 years old).
Sagittal, coronal and three-dimensional (3D) reconstructions
were studied by RadiAnt DICOM Viewer® 4.6.9 with aim
to detect BVF and BVC morphology and measure the BVC
depth. Based on imaging, the BVC shape was classified as
triangular, trapezoid and irregular.
Statistical analysis
Statistical analysis was performed with IBM SPSS Statistics
23.00 software and significance level was set to p = 0.05.
Fischer exact test was used to detect differences between
BVF number and spine section, gender or age group. For
quantitative variables, Shapiro–Wilk test of normality was
performed in each subgroup. In normalized data, depend-
ent t-test was used to test for differences between different
sides at the same vertebral level and between vertical and
horizontal BVF diameter. Independent t-test (with respect
to Levene’s test) was used to indicate differences of quan-
titative variables between gender, age groups in CT sub-
group and between cases with one or two BVF. Finally,
13
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Fig. 3  Example of a cumula-
tive topographic graph of the
basivertebral foramina (BF)
area distribution at the same
vertebral level
One-way ANOVA was used to compare means between
age groups, and post hoc analysis with Bonferroni correc-
tion was applied when appropriate. Depending on Levene’s
test results, Welch’s ANOVA and Games-Howell post hoc
correction was preferred. If non-parametric analysis was
necessary, Wilcoxon Signed Rank, Mann–Whitney U and
Kruskal–Wallis tests were used, accordingly. Correlation
between VB morphometry and the area including BVF, as
well as BVC depth, per vertebral level, was examined using
Spearman correlation coefficient. The values less than 0.4
were considered low, 0.4–0.7 medium and values greater
than 0.7 strong correlations. Statistical tests used for each
comparison and the p values are presented in Tables 1–5 of
the Electronic Supplementary Material. Linear graphs were
preferred and created by SPSS and Miscrosoft Excel®, to
emphasize the differences among vertebral column levels
and different studies.
Results
Vertebral body measurements
Among vertebral levels, mean anteroposterior VB diameter
ranged from 13.37 mm to 35.35 mm and mean laterolat-
eral from 18.98 mm to 50.91 mm. Additionally, minimum
mean anterior height was found 12.41 mm and maximum
28.17 mm. Mean posterior height ranged from 13.32 mm
to 27.71 mm, while minimum mean distance between pedi-
cles was 14.03 mm and maximum 25.64 mm. Mean values
and standard deviation, as well as statistical analysis of VB
measurements for each vertebral level are summarized in
Table 2. In measurements with statistically significant differ-
ence between genders, male mean values were greater than
female. The mean posterior height of the odontoid process
was 17.46 mm ± 2 mm (range 12.95 mm–24.02 mm).
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Surgical and Radiologic Anatomy (2021) 43:889–907
Basivertebral foramina number, location and shape
None of C­ 1 vertebrae presented BVF (3.4% of total cases).
One BVF was found in 45.1% of the total vertebrae,
located at the center in the majority of cases (Fig. 4). Two
BVF, mainly of similar size, were noted in 36.9% (Fig. 5),
three in 3.8%, four in 0.6%, whereas five BVF were found
in one case (0.06%) (Fig. 6). In 10.1% of total vertebrae,
only small (< 1 mm in diameter) multiple foramina were
identified in the posterior aspect of the VB. In 2.9% of
vertebrae, a single left-sided BVF was identified and a
right-sided one in 1.8%. In 4.4% of total cases, the midline
BVF was divided by osseous bridge in two (4.2%) or three
(0.2%) parts. In 2.9% of total cases, two BVF of unequal
size were found, (one on each side); in 1.8%, the left-sided
BVF was larger. In 1.2% of the cases, a midline BVF along
with a second one left- (0.65%) or right-sided (0.55%)
was noted and in 0.2% two left-sided BVF were found. A
schematic representation of all found variants is depicted
in Fig. 7. Based on this classification, lack of morphologi-
cal symmetry was noted in cases 1b, 2b-e, 3b-e, 4c, 4d
and 5, thus in 12.3% of total cases. The BVF shape was
irregular in 66.7% of cases, oval in 12.3%, round in 11.8%,
fissure-like in 7.7% and heart-like in 1.4% (Fig. 8). The
BVF number varied between vertebral levels (Table 3).
In ­C2 vertebrae, two BVF were noted in 72.2% (Fig. 9),
and one BVF was noted in ­T10, ­T11, ­T12 and ­L1 in frequen-
cies 76.8%, 84.8%, 86.6% and 84.3%, respectively. This
pattern was considered typical. C ­ 3 and T­ 2 vertebrae pre-
sented the greatest variability in BVF number. Concern-
ing the gender impact, the BVF number showed gender
dimorphism in C ­ 6 and T
­ 2 vertebrae. No differences were
found between age groups in any level. Differences in BVF
number in between cervical, thoracic and lumbar spine
were statistically significant (Fisher Exact test, p = 0.0).
BVF number varied among different spines.
Surgical and Radiologic Anatomy (2021) 43:889–907 893

Table 2  Mean value and standard deviation (SD) of the vertebral body measurements, in mm
Vertebral body
morphometry
Vertebrae APD LLD AH PH P

mean ± SD diff mean ± SD diff mean ± SD diff mean ± SD diff mean ± SD diff
C2 13.37 ± 1.46 M 18.98 ± 1.82 M 22.17 ± 2.4 M 17.46 ± 2.17 M 17.26 ± 1.74 M
C3 16.23 ± 1.75 M 22.04 ± 1.97 – 13.08 ± 1.3 M 13.84 ± 1.64 M 18.58 ± 2 M
C4 16.92 ± 2.1 M 23.49 ± 2.47 – 12.71 ± 1.57 M 13.32 ± 1.35 M 19.88 ± 1.77 M
C5 17.66 ± 2.48 M 25.54 ± 2.79 – 12.41 ± 1.57 M 13.57 ± 1.59 M 20.41 ± 2.14 M
C6 18.86 ± 2.65 1–3 28.46 ± 3.13 – 12.59 ± 1.58 M 13.32 ± 1.35 M 21.36 ± 1.86 M
2–3
(1 < 2 < 3)
C7 19.05 ± 2.45 1–3 30.52 ± 2.94 1–3 14.52 ± 1.71 M 14.83 ± 1.41 M 20.82 ± 2.19 –
2–3 (1 < 2 < 3)
(1 < 2 < 3)
T1 18.54 ± 1.98 M 30.66 ± 2.8 M 16.4 ± 2.09 M 17.4 ± 1.7 M 17.81 ± 1.64 –
T2 19.51 ± 2.02 M 29.97 ± 2.25 M 17.72 ± 1.75 M 18.01 ± 1.85 M 15.69 ± 1.59 M
1–3
(1 < 2 < 3)
T3 21.06 ± 2.41 M 27.64 ± 2.19 M 18.36 ± 1.57 M 18.63 ± 1.69 M 14.13 ± 1.48 –
T4 23.2 ± 2.26 M 26.8 ± 2.45 M 18.24 ± 1.69 M 19.22 ± 1.65 M 14.03 ± 1.39 M
1–2
2–3
(1 < 3 < 2)
T5 24.69 ± 2.16 M 27.42.66 M 18.35 ± 1.81 M 19.79 ± 1.65 M 14.25 ± 1.43 M
T6 26.07 ± 2.17 M 28.65 ± 3.07 M 18.66 ± 1.92 M 20.5 ± 1.8 M 14.18 ± 1.58 –
T7 27.51 ± 2.04 M 30.02 ± 3.03 M 19.1 ± 2.13 M 21.07 ± 1.86 M 14.37 ± 1.4 –
1–3
(1 < 2 < 3)
T8 29.04 ± 2.41 M 31.17 ± 2.92 M 19.56 ± 2.03 M 21.28 ± 1.91 M 14.8 ± 1.4 M
T9 30.04 ± 2.78 M 32.84 ± 2.88 M 20.33 ± 1.89 M 21.95 ± 1.77 M 15.2 ± 1.64 M
1–3
(1 < 2 < 3)
T10 30.77 ± 2.64 M 34.62 ± 3.62 M 21.53 ± 2.3 M 23.05 ± 1.89 M 15.66 ± 1.66 –
T11 30.79 ± 2.54 M 37.84 ± 3.23 M 22.07 ± 2.47 M 24.92 ± 2.37 M 17.48 ± 1.81 –
1–2
(1 < 3 < 2)
T12 31.39 ± 3 M 39.55 ± 3.69 M 23.42 ± 2.98 M 26.26 ± 2.26 M 20.63 ± 2.17 –
L1 32.07 ± 2.74 M 39.44 ± 3.56 M 25.08 ± 3.44 M 27.33 ± 2.23 M 21.23 ± 1.72 –
L2 33.69 ± 2.97 M 41.09 ± 4.27 M 27.14 ± 2.06 M 27.71 ± 2.18 M 21.39 ± 1.97 –
1–3
(1 < 2 < 3)
L3 34.84 ± 2.9 – 43.14 ± 4.08 M 27.49 ± 2.42 M 27.23 ± 2.42 M 21.87 ± 1.72 –
1–3
(1 < 2 < 3)
L4 35.48 ± 3.32 M 46.08 ± 4.7 M 27.56 ± 2.55 M 26.55 ± 2.53 M 22.45 ± 1.9 M
1–3
(1 < 2 < 3)
L5 35.35 ± 3.1 M 50.91 ± 4.85 M 28.17 ± 2.57 M 23.89 ± 2.59 M 25.64 ± 2.99 –

Cases with mean male (M) values statistically significant greater than female and/or significant mean differences among age groups
(1: < 55 years old, 2: 55–75 years old and 3: ≥ 75 years old) are noted in column named diff
APD anteroposterior diameter, LLD laterolateral diameter, AH anterior height, PH posterior height, P distance between pedicles

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894
Fig. 4  Location of one basivertebral foramen a midline, b right-sided, c midline with an osseous bridge dividing it into 2 parts, d midline with
an osseous bridge dividing it into 3 parts
Basivertebral foramina topography
BVF were found significantly closer to the upper vertebral
body rim in ­C2 and ­T10–L4 vertebrae, whereas they were
significantly closer to the lower rim in ­C7–T4, ­T6–T8 and
­L5. No statistically significant differences were recorded
between mean distances from pedicles in any vertebral
level (Table 4). Particularly in C ­ 2, most BVF were located
at the upper half of the VB, as their mean distance from
the lower VB rim corresponded to the 50.7% of the VB
posterior height. The mean BVF area ranged from 5.11 to
10.25% of the VB posterior aspect, among different verte-
bral levels. BVF area differentiated between genders and
age groups only in L ­ 1 and ­T4 vertebrae, respectively. In
male ­L1 vertebrae, the mean BVF area was significantly
greater compared to female, whereas in ­T4, it was signifi-
cantly greater in the age group of ≥ 75 years. Furthermore,
BVF area presented low positive correlation to the dis-
tance between pedicles in C ­ 5, ­T1 and L
­ 4, to the anterior
height in T­ 3 and T
­ 7, to the T
­ 11 laterolateral diameter and
to the T
­ 12 anteroposterior diameter and posterior height.
Medium positive correlation of the BVF area and the dis-
tance between pedicles was found in ­C3 vertebrae. Cumu-
lative BVF topographic graphs are presented in Fig. 10.
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Surgical and Radiologic Anatomy (2021) 43:889–907
Basivertebral foramina diameters
BVF mean vertical diameter was significantly greater than
the mean horizontal in C ­ 2–C6, ­T1, ­T2, ­T7–T9 and L
­ 2–L5 ver-
tebrae, whereas in ­L1 vertebrae, the mean horizontal diam-
eter was greater. In cases with two BVF (one located at each
VB side), no significant differences in mean BVF size were
found. The mean size of midline single BVF was signifi-
cantly greater than the size of the left- or right-sided BVF, in
all vertebral levels (Fig. 11). BVF diameters are summarized
in Table 5.
Basivertebral canals shape and depth (computed
tomography study)
CT examination allowed the recognition of BVF number
and morphology (Fig. 12). The BVC had irregular shape in
54.9%, triangular in 23.4% and trapezoid in 21.7%, whereas
in 14.2% of the cases, an osseous septum was identified
inside the BVC (Fig. 13). The mean BVC depth corre-
sponded to the 12–21.8% of the anteroposterior VB diam-
eter, through different vertebral levels. Significant greater
mean values were found in male specimens in ­T4 and ­T6
(Table 6). No other differences among genders or age groups
Surgical and Radiologic Anatomy (2021) 43:889–907
Fig. 5  Location of two basivertebral foramina a of similar size, located at each side of the vertebral body posterior aspect, b of different size,
located at each side, the right greater than the left, c a midline and a second left-sided, d left-sided
were detected. BVC depth presented medium positive corre-
lation to the ­T3 VB anteroposterior diameter, medium posi-
tive correlation to the T
­ 6 laterolateral diameter and distance
between pedicles. Strong positive correlation was found
between BVC depth and ­T6 VB laterolateral diameter, as
well as ­T4 distance between pedicles, anteroposterior and
laterolateral VB diameters.
Discussion
Few studies have been published concerning BVF anatomy
[22–24, 30]. In Asian literature, Ma et al. [22–24] studies
described BVF number, topography and area in 161 cervical,
276 thoracic and 115 lumbar dried vertebrae, of unknown
gender and age of death. A higher BVF number was reported
per vertebra in the aforementioned literature, except from
­T1 level (Fig. 14); however, possibly smaller foramina were
included [22–24]. No nutrient foramina were described at
the center of the anterior arch posterior aspect [24], as it
occurs in the present study. One or two foramina were found
close to the transverse ligament tubercles of ­C1 by Ma et al.
[24]. Ma et al. found that BVF were significantly closer to
the upper VB rim in C ­ 2, ­C4, ­T10, ­T12 and L
­ 3, and closer to
895
the left pedicle in T ­ 4, ­T8 and ­T11 [22–24]. In the current
study, BVF were closer to the upper rim in ­C2 and T ­ 10 and
closer to the lower VB rim in ­C7, ­T4, ­T6 and ­T8 vertebrae. No
significant differences were found between mean distances
from the left and right pedicle. The mean area including
BVF per vertebra level as present by Ma et al. [22–24] and
the current study is described in Fig. 15. Differences greater
than 0,1cm2 in the area including BVF were noticed in ­C7,
­T1–T5 and ­L2–L5 vertebrae.
Tubbs et al. [30] studied the BVF anatomy in ­C2 vertebrae
and found that the BVF were located at 30–44% of the total
posterior height, whereas in the present study, the mean BVF
distance from the lower rim was 25.3–34.9% of the posterior
height (including the odontoid process height). Addition-
ally, Tubbs et al. [30] noted that ­C2 BVF had circular shape
in 50%, were multiple in 20%, while one and two fissure-
like BVF were found in 20% and 10%, respectively. In our
sample, two BVF were noted in 72.2%, one BVF in 13%
and only small multiple foramina were observed in 9.3% of
­C2. The majority of BVF cases were fissure-like (64%). The
mean BVF diameter was found 2.7 mm by Tubbs et al. [30],
whereas in the current study, the mean vertical and hori-
zontal diameters were 2.73 mm and 1.25 mm, accordingly.
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896 Surgical and Radiologic Anatomy (2021) 43:889–907

Fig. 6  Multiple basivertebral foramina (BVF) a 3 BVF b 4 BVF c 5 BVF d Numerous small (< 1 mm) BVF

Fig. 7  Schematic representation of all basivertebral foramina (BVF) morphologic variants found, regardless vertebral level and side. All varia-
tions depicted unilaterally were spotted at the opposite side as well (with the exception of 2d cases)

13
Surgical and Radiologic Anatomy (2021) 43:889–907
Fig. 8  Schematic representation of basivertebral foramina shape a irregular, b oval, c circular, d fissure-like and e heart-like
BVF anatomy in thoracic and lumbar spine has also been
studied in healthy population by CT [15, 16, 35, 40]. Study-
ing ­T12–L5 vertebrae of adults younger than 55 years old,
Zhao et al. [40] found that BVC shape was triangular or
trapezoid in 81%, irregular in 11% and polygonal in 8%. An
osseous septum inside the BVC was identified in 6%, while
BVF were found significantly closer to the upper VB rim
in all levels. Kang et al. [15, 16] studying BVC anatomy
and depth in thoracic and lumbar spines of adults younger
than 55 years old, found the BVC shape triangular in 48%,
irregular in 27% and trapezoid in 25%, whereas distances
from the upper and lower rims of the VB were not signifi-
cantly different in the thoracic vertebrae. In lumbar spine,
an osseous septum inside BVC was found in 8% of cases
[16]. In T
­ 8–L5 vertebrae of healthy subjects 30–70 years of
age, the BVF occurred in only 76.75% of cases and located
significantly closer to the upper rim in all levels [16]. The
mean BVC depth, as presented by the current study and the
aforementioned literature [15, 16, 35, 40], is presented in
Fig. 16. Variances between the present study and the litera-
ture may be due to population and methodology differences.
Clinical considerations
BVF have been associated with the diagnosis, mechanism
and pathophysiology of spinal fractures. BVC are located
at the center of VB in axial planes of CT scans and may
be misdiagnosed as VB fractures [14, 27], whereas in ­C2
vertebrae, their alignment with the subdental synchondro-
sis could assist in fractures classification [30]. In thoracic
and lumbar burst fractures, retropulsed bony fragments are
common and usually arising from the VB superior aspect,
897
with the fracture line coursing throughout BVF, leading to
the upper BVC wall detachment [1, 11, 19]. These obser-
vations point out that the BVF may play a key role in VB
fractures, as it naturally “weakens” the posterior aspect and
the middle axial plane of the VB, especially in cases with a
unique midline large BVF. Interestingly, in the present study,
unique midline BVF were identified in over 50% of cases in
thoracolumbar junction ­(T10–L2), while the mean vertical
and horizontal diameters of them in ­T12–L4 vertebrae were
greater than the 1/4 of the VB posterior height and the 1/5
of the distance between pedicles, respectively. Additionally,
in all thoracic and lumbar vertebrae, mean BVC depth is
greater than 14% of the VB anteroposterior diameter. The
BVC integrity in fractured vertebrae has also been associ-
ated with a better clinical outcome [13], as collapsed canals
may indicate VB blood supply interruption [34] and con-
sequently increase post-traumatic pain and jeopardize the
healing process.
Vertebral augmentation techniques have been commonly
used in neurosurgical practice to treat VB painful osteo-
porotic or malignant fractures and strengthen the spinal
instrumentation in selected cases [4, 6, 8, 10, 12, 17, 20, 21,
26, 28, 31–33, 36–38]. In a large meta-analysis published
in 2017, the weighted mean incidence of cement leakage
was 59.7% in vertebroplasty and 18.4% in kyphoplasty
cases [38]. Cement leakage may occur through traumatic
or iatrogenic cortical defects into the spinal canal, intra-
vertebral foramina, intravertebral and intradiscal space,
or through the basivertebral vessels. Several cases of lung
and cerebral cement embolization have been published [7,
19, 25]. Cement leakage through the basivertebral veins is
commonly characterized as type B leakage [36]. Type B
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898 Surgical and Radiologic Anatomy (2021) 43:889–907

Table 3  Basivertebral foramina (BVF) number and symmetry percentage at different vertebral levels
Basivertebral foramina number
Vertebrae 0 1 (midline 2 3 4 5 Small numer- Symmetry (%)
located) ous (< 1 mm)

C1 53 – – – – – – –
C2 – 10 (7) 39 – – – 5 94.4
C3 – 3 (1) 24 2 – – 23 92.3
C4 – 9 (3) 32 2 – – 17 83.3
C5 – 10 (5) 26 4 – – 21 75.4
C6 – 10 (5) 31 5 3 – 11 73.3
F: 9 (5) F: 13 F: 4 F: 0 F: 6
M: 1 (0) M: 18 M: 1 M: 3 M: 5
C7 – 12 (11) 43 4 1 – 7 83.6
T1 – 15 (15) 44 1 – – 7 94
T2 – 30 (27) 31 2 – – 5 89.7
F: 9 (8) F: 20 F: 1 F: 3
M: 21 (19) M: 11 M: 1 M: 2
T3 – 42 (41) 23 2 – 1 2 92.9
T4 – 44 (39) 21 – – – 4 88.4
T5 – 39 (35) 18 2 – – 9 83.8
T6 – 42 (36) 21 – – – 6 88.4
T7 – 33 (26) 26 1 1 – 6 82.1
T8 – 36 (29) 24 – 1 – 7 83.8
T9 – 36 (32) 24 2 – – 7 89.9
T10 – 53 (50) 9 2 – – 5 91.3
T11 – 56 (54) 6 – 1 – 3 93.9
T12 – 58 (56) 5 – – – 4 95.5
L1 – 59 (56) 7 – 1 – 3 90
L2 – 42 (41) 19 6 – – 2 85.5
L3 – 35 (34) 24 7 2 – – 91.2
L4 – 15 (14) 40 10 – – – 80
L5 – 15 (13) 40 7 – – 4 81.8
Total 53 704 (630) 577 59 10 1 158 87.7

In cases of statistically significant difference, BVF number of female (F) and male (M) vertebrae are noted in bold

leakage is found in up to 54% of percutaneous augmentation
technique cases [24–30] and in 23% of cement augmented
spine fixation [12], while in cervical spine, leakage within
the basivertebral and epidural venous plexus is noted in 5%
[6]. It is suggested by Wang and Zhao [33] that type B leak-
age may not only occur via the basivertebral vessels, but also
through BVC and BVF.
Especially in cases with intravertebral clefts, higher risk
of cement leakage has been found in two published meta-
analyses [37, 38], contrariwise to other studies [8, 20, 28].
Wang et al. [32] in their study on the association between
type B cement leakage and intravertebral clefts, concluded
that the communication between BVF and intravertebral
clefts may act as a risk factor for material extrusion; such
communication was also reproduced in vitro [4]. In another
in vitro study of ­T12–L5 vertebrae compression fractures, Li
et al. [21] studied the significant trabecular microstructure
damage of the central 1/3 of the VB after mechanical testing,
associating the acquired intervertebral spacing with type B
cement leakage.
In Bokov et al. [3] study, a total of 150 ­T11–L5 vertebrae
were treated with vertebroplasty, after low energy vertebral
compression fractures and the BVF morphology was associ-
ated with cement leakage. In detail, a midline single (magis-
tral) BVF was found in 43% of cases and small foramina in
57%. In 19% of total cases, cement leakage into the spinal
canal was observed. A greater incidence of cement leakage
was observed in cases with a midline single BVF, as cement
leakage was noted in 34% of these patients. The authors con-
cluded that BVF morphology should be taken into account
when planning a percutaneous vertebral augmentation. Fur-
thermore, cement leakage may be avoided by entering the

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Surgical and Radiologic Anatomy (2021) 43:889–907 899

Fig. 9  A. Typical basivertebral foramina distribution in a ­C2 vertebra b Three dimensional reconstruction in computed tomography scan

Table 4  Basivertebral foramina (BVF) topography

Vertebrae Upper Lower Left Right Area
Mean ± SD % Mean ± SD % Mean ± SD % Mean ± SD % Mean ± SD %

C2 5.24 ± 1.28 50.7 8.87 ± 1.74 70 6.4 ± 1.34 39.2 6.34 ± 1 67.2 16.98 ± 17.66 5.51
C3 5.38 ± 1.19 37.1 5.15 ± 1.18 61 5.57 ± 1.23 30.3 5.47 ± 1.14 70.3 27.13 ± 19.37 10.25
C4 5.47 ± 0.84 38.7 5.49 ± 0.88 61.2 6.39 ± 1.16 32.4 6.45 ± 1.12 66.2 21.01 ± 15 7.94
C5 5.81 ± 1.13 38.3 5.75 ± 1.04 61.2 6.59 ± 0.934 32.6 6.76 ± 1.03 67.3 23.52 ± 18.03 8.39
C6 5.31 ± 0.98 38 5.09 ± 1.09 60.2 6.75 ± 1.94 31.5 6.72 ± 2.87 68.6 24.67 ± 15.73 8.74
C7 6.14 ± 1.12 37 5.48 ± 0.94 58.7 6.15 ± 1.28 29.5 6.05 ± 1.42 71 28.3 ± 14.58 9.25
T1 7.45 ± 1.19 36.1 6.3 ± 1.13 57.2 5.09 ± 1.11 28.5 5.07 ± 1.17 71.6 28.39 ± 12.8 9.2
T2 7.45 ± 1.35 37.1 6.69 ± 1.25 58.8 4.78 ± 1.41 30.5 4.61 ± 1.15 70.6 25.07 ± 14.02 8.98
T3 7.64 ± 1.2 39.1 7.31 ± 1.42 59 4.34 ± 1.01 30.6 4.32 ± 1.02 69.4 20.86 ± 12.73 7.99
T4 8.05 ± 1.02 41.2 7.93 ± 1.2 58.1 4.44 ± 1.23 31.4 4.54 ± 1.22 67.9 17.52 ± 11.71 6.62
T5 8.52 ± 1.2 42.5 8.43 ± 1.08 57 4.71 ± 1.03 33.2 4.78 ± 1.13 66.5 14.1 ± 8.09 5.11
T6 9 ± 1.01 41 8.42 ± 1.25 56 4.93 ± 1.09 34.7 4.98 ± 1.33 65.1 13.59 ± 8.31 4.76
T7 9.06 ± 0.99 41.2 8.77 ± 0.99 55.7 4.46 ± 0.79 34.7 4.36 ± 0.66 72.3 14.8 ± 9.85 4.88
T8 9.22 ± 1.1 41.1 8.8 ± 1.22 57.3 4.66 ± 0.88 33.1 5.04 ± 0.78 65.5 17.35 ± 10.76 5.58
T9 9.29 ± 0.99 40.9 9.14 ± 1.07 58.4 4.52 ± 0.62 32 4.63 ± 0.79 67 21.18 ± 11.13 6.48
T10 9.33 ± 1.45 40.5 9.55 ± 1.52 61.1 4.84 ± 0.95 31.7 4.7 ± 0.92 68.3 28.77 ± 17.82 8.07
T11 9.53 ± 1.54 42.2 10.53 ± 1.55 61.9 5.81 ± 1.37 33.1 5.61 ± 1.23 68 30.96 ± 17.38 7.23
T12 10.22 ± 1.32 41.9 10.97 ± 1.38 61.1 7.1 ± 1.55 34.3 6.75 ± 1.7 67.3 37.04 ± 22.15 6.85
L1 10.62 ± 1.49 42 11.49 ± 1.67 61.1 6.97 ± 1.35 32.8 6.97 ± 1.83 67.2 40.64 ± 24.79 7.08
L2 10.61 ± 1.42 41.5 11.53 ± 1.67 61.7 6.74 ± 1.39 31.4 6.82 ± 1.59 68.2 44.85 ± 19.95 7.67
L3 10.56 ± 1.36 41.7 11.36 ± 1.66 61.2 6.87 ± 1.51 31.3 6.81 ± 1.35 68.9 44.3 ± 19.01 7.48
L4 10.55 ± 1.33 42.1 11.18 ± 1.64 60.3 7.28 ± 1.31 32.5 7.17 ± 1.22 68 40.2 ± 21.54 6.7
L5 10.29 ± 1.71 40.1 9.56 ± 1.69 57 8.3 ± 2.09 32.3 8.43 ± 2.3 67.3 37.56 ± 28.33 6.23

Mean value and standard variation (SD) of the distances between the upper and lower vertebral body rims and the BVF closest to them, as well
as the left and right pedicles and the BVF closest to them (in mm). The percentage corresponds to the mean relative position of BVF in the verti-
cal and horizontal axes. In the final column, the mean rectangular area including BVF is provided in m­ m2 and as percentage of the mean poste-
rior aspect surface area

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900 Surgical and Radiologic Anatomy (2021) 43:889–907

Fig. 10  Cumulative topographic graphs of the basivertebral foramina distribution for each vertebral level. The vertical and horizontal axes ratio
is the true ration between mean posterior height and mean distance between pedicles for each vertebral level

needle tip into the lateral 1/3 of the VB, especially in cases the BVF and BVC anatomy, contributing in preoperative
with a single midline BVF [3]. The present study revealed planning (Fig. 17).
that BVF are commonly located in the middle 1/3 of the
distance between pedicles and CT scan can depict in detail

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Surgical and Radiologic Anatomy (2021) 43:889–907 901

Fig. 11  Linear graphs showing the mean vertical and horizontal diameters (in mm) of left, midline and right basivertebral foramina (BF) through
different vertebral levels

Table 5  Mean value and Basivertebral foramina location

standard deviation (SD) of
basivertebral foramina (BVF) Vertebrae Left-sided BVF (mean ± SD) Midline BVF (mean ± SD) Right-sided BVF
diameters, based on their (mean ± SD)
location (in mm)
Vertical Horizontal Vertical Horizontal Vertical Horizontal

C2 2.7 ± 0.88 1.19 ± 0.28 2.97 ± 0.78 2.5 ± 1.14 2.73 ± 0.88 1.13 ± 0.21
C3 2.05 ± 0.69 1.33 ± 0.39 2.03 ± 0.7 1.52 ± 0.64 1.98 ± 0.63 1.35 ± 0.38
C4 1.99 ± 0.54 1.47 ± 0.57 2.47 ± 0.95 2.45 ± 1.12 2.17 ± 0.73 1.55 ± 0.58
C5 2 ± 0.71 1.6 ± 0.73 2.59 ± 0.68 2.35 ± 1.44 2 ± 0.61 1.52 ± 0.6
C6 2.18 ± 0.68 1.8 ± 0.76 2.09 ± 0.74 2.93 ± 2.08 2.16 ± 0.74 1.95 ± 0.81
C7 2.67 ± 0.68 2.66 ± 0.95 2.77 ± 1.12 5.71 ± 2.76 2.56 ± 0.82 2.35 ± 0.81
T1 3.07 ± 0.99 2.18 ± 0.94 3.73 ± 1.22 6.86 ± 2.4 2.9 ± 0.9 2.22 ± 1.02
T2 0.344 ± 1.3 2.1 ± 0.95 3.6 ± 1.35 5.79 ± 1.62 3.1 ± 1.17 1.99 ± 0.81
T3 2.89 ± 1.05 1.84 ± 0.58 3.54 ± 1.53 5.15 ± 1.47 2.92 ± 0.87 1.76 ± 0.53
T4 2.89 ± 1.18 2.05 ± 0.75 3.14 ± 1.33 4.67 ± 1.66 2.99 ± 1.17 1.92 ± 0.84
T5 2.16 ± 0.58 1.82 ± 0.53 2.83 ± 1.01 4.23 ± 1.46 2.3 ± 0.88 1.66 ± 0.73
T6 2.47 ± 1.01 1.69 ± 0.59 2.84 ± 0.82 3.91 ± 1.02 2.69 ± 1.18 1.59 ± 0.54
T7 2.11 ± 0.89 1.54 ± 0.59 2.86 ± 0.99 3.94 ± 1.64 2.28 ± 0.91 1.73 ± 0.55
T8 2.78 ± 1.19 1.61 ± 0.62 3.2 ± 0.87 4.59 ± 1.43 2.52 ± 1.18 1.47 ± 0.48
T9 2.53 ± 1.08 1.76 ± 0.63 3.95 ± 1.18 4.74 ± 1.85 2.62 ± 1.08 1.8 ± 0.61
T10 3.15 ± 1.19 1.87 ± 0.52 4.49 ± 1.96 5.48 ± 2.05 3.41 ± 1.58 3.15 ± 1.19
T11 4.19 ± 1.95 2.94 ± 1.25 4.83 ± 1.33 5.74 ± 1.49 4.89 ± 1.92 2.66 ± 1.45
T12 5.2 ± 1.54 3.63 ± 1.18 4.96 ± 1.63 6.36 ± 1.87 4.99 ± 1.89 3.54 ± 1.18
L1 4.3 ± 1.9 3.23 ± 1.28 4.98 ± 1.58 6.82 ± 2.31 4.28 ± 2.08 2.82 ± 0.89
L2 4.35 ± 1.56 2.73 ± 0.98 4.93 ± 1.45 6.36 ± 2.51 4.47 ± 2.06 2.69 ± 1.04
L3 4.52 ± 1.45 2.7 ± 1 5.16 ± 1.73 6.57 ± 2.5 4.18 ± 1.44 2.69 ± 0.96
L4 4.21 ± 1.49 2.51 ± 1 3.42 ± 1.58 3.71 ± 2.35 3.97 ± 1.66 2.49 ± 0.92
L5 3.24 ± 1.18 2.37 ± 1.07 2.93 ± 1.24 4.31 ± 2.54 2.91 ± 1.17 2.28 ± 0.8

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902 Surgical and Radiologic Anatomy (2021) 43:889–907

Fig. 12  Computed tomography findings of basivertebral foramina with osseous bridge in coronal section d two BVF of similar (Di) and
(BVF) morphology. a One midline BVF in axial (Ai) and sagittal uneven (Dii) size, in axial section
(Aii) section b One right-sided BVF in axial section c Midline BVF

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Surgical and Radiologic Anatomy (2021) 43:889–907
Fig.13  Basivertebral canals
shape a irregular, b triangular,
c trapezoid. d presence of osse-
ous septum in the basivertebral
canal
Finally, intraosseous basivertebral nerve radiofrequency
ablation is a novel technique for the treatment of chronic
vertebrogenic low back pain applied in ­L3 to ­S1 vertebrae.
The first clinical trial describing the potential of this pro-
cedure was published in 2017, reporting clinical success in
81% of patients [2]. The relative position of the basiverte-
bral nerve branch and termination point is noted preopera-
tively and thermal ablation of the nerve is achieved using a
transpendicular delivery system (INTRACEPT®), creating
a spherical lesion 1 cm in diameter [2]. Concerning the
efficacy and safety of the technique and patients’ inclusion
criteria more studies have been published since 2017 [9,
18, 29]. In the aforementioned studies, the target point is
suggested to be found in 40–60% [9] or 30–50% [18, 29]
of the anteroposterior VB diameter, while Becker et al.
[2] mentioned that the distance between the target point
and the posterior VB aspect ranged from 10 to 18 mm
(mean 13 mm). Targeting success was noted in over 91%
of cases [2, 9, 18, 29]. In the current study, the mean BVC
depth was over 14.1% of the anteroposterior VB diameter
in lumbar spine and gradually increased caudally.
903
Study limitations
Research of exclusively dried adults’ vertebrae and lack of
medical history knowledge constitute study’s limitations.
No young skeletons could be investigated. An additional
limitation was the low number of examined vertebrae by
CT scan. Further cadaveric (dry and fresh material) and
clinical research is encouraged to examine potential further
correlations and differences among healthy and pathological
subjects in different populations.
Conclusions
The present study describes in detail the BVF number,
shape, size and topography in dried spines, per vertebral
level. Briefly, ­C 1 lacks BVF, while mainly one or two
BVF were found in the majority of the studied vertebrae.
Only small (< 1 mm) multiple foramina were observed
in 10.1%. ­C2 and ­T10–L1 presented typical BVF pattern,
with one and two BVF found, respectively. ­C 3 and ­T 2
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904 Surgical and Radiologic Anatomy (2021) 43:889–907

Table 6  Mean and standard deviation (SD) of basivertebral canal

(BVC) depth (in mm and as a percentage of the mean anteroposterior
vertebral body diameter) and BVC shape

BVC morphometry
Vertebrae Depth Shape
Mean ± SD % Trapezoid Triangular Irregular

C2 2.49 ± 0.69 15.3 3 0 7

C3 2.2 ± 0.59 13.9 0 0 10
C4 2.3 ± 0.45 14.3 0 0 8
C5 2.06 ± 0.69 12 0 0 9
C6 2.4 ± 0.72 12.9 1 0 9
C7 2.6 ± 0.95 14.1 1 0 9
T1 2.93 ± 1.35 16.1 1 2 7
T2 4.14 ± 1.57 21.8 0 6 4 Fig. 15  Linear graph showing the mean area (in ­cm2) that included
T3 4.54 ± 1.27 21.6 3 5 2 basivertebral foramina, among vertebral levels, as described in the lit-
erature [22–24] and in the present study
T4 4.67 ± 1.11a 20.8 0 6 4
T5 3.6 ± 1.05 15.1 2 2 6
T6 4.17 ± 1.23a 16.2 2 4 4
T7 4.41 ± 1.16 16 1 4 5
T8 4.06 ± 1.38 14.2 2 2 6
T9 4.15 ± 1.07 14.1 3 2 5
T10 4.7 ± 0.95 15.5 0 5 5
T11 5.54 ± 1.87 18.3 3 5 2
T12 4.77 ± 1.75 15.6 2 3 5
L1 4.41 ± 1.46 14.1 4 3 3
L2 5.4 ± 1.26 16.2 6 2 2
L3 6.74 ± 1.22 19.7 5 1 4
L4 6.68 ± 2.24 19.3 6 1 3
L5 6.97 ± 2.46 20.4 4 0 5
Total 49 53 124
a
Statistically significant difference between genders

Fig. 16  Linear graph showing the mean basivertebral canal depth

(in mm), as reported in the literature [15, 16, 35, 40] and the present
study. Both studies by Kang et al. [15, 16] are shown in green color

showed the greatest variability. A detailed morphological

classification and cumulative BVF location graphs are
Fig. 14  Linear graph showing the mean number of basivertebral
foramina reported in the literature [22–24] and in the present study, provided. As far as topography is concerned, BVF were
among vertebral levels found significantly closer to the upper VB rim in ­C2 and

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Surgical and Radiologic Anatomy (2021) 43:889–907
Fig. 17  Computed tomography findings of basivertebral foramina (BVF) number and distribution. a one midline BVF b one midline BVF with
osseous bridge c three BVF and d two BVF
­T10–L4 and to the lower rim in ­C7–T4, ­T6–T8 and ­L5. No
significant difference between mean distances from the
left and right pedicles was found. Finally, the mean BVC
depth was 12–21.8% of the anteroposterior VB diameter.
Due to the aforementioned clinical impact of the BVF
and BVC and increased research interest in the area, the
present findings will assist in clinical practice and act as
a guide for future reference.
Acknowledgements The authors wish to thank all body donors and
their families for their special gift of donation and their valuable con-
tribution to the anatomy education and research.
Author contributions Maria Tzika: conceptualization, protocol devel-
opment, data collection and analysis, writing and original draft prepara-
tion, George Paraskevas: protocol development, visualization, Maria
Piagkou: protocol development, reviewing and editing, Apostolos
Papatolios: data collection, Konstantinos Natsis: manuscript editing
and supervision.
Funding No funding was received for the study’s conduction. The
authors have no relevant financial or non-financial interests to disclose.
Availability of data and materials Any interested part is invited to con-
tact the Department of Anatomy and Surgical Anatomy, School of
Medicine, Faculty of Health Sciences, Aristotle University of Thes-
saloniki, Thessaloniki, Greece, for access to data and material.
Compliance with ethical standards
Conflict of interests The authors have no conflict of interest relevant to
the content of this article.
Ethics approval and consent The osseous material was part of the body
donors’ corpses (body donation before death after written informed
consent) and of the unclaimed cadaveric bodies which were dissected
in our University according to current legislation and the Declaration
905
of Helsinki, adopted by the 18th World Medical Association General
Assembly in 1964 and amended in 2013. Ethics Committee of our
University approved the study protocol.
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