Original Article

Global Spine Journal

2023, Vol. 13(3) 705–712
Analysis of Sagittal Thoracic Inlet Measures ª The Author(s) 2021
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in Relation to Anterior Access to sagepub.com/journals-permissions

DOI: 10.1177/21925682211005730
journals.sagepub.com/home/gsj
the Cervicothoracic Junction

Joseph F. Baker, MCh, FRCSI1,2

Abstract
Study Design: Retrospective radiographic study.
Objective: The aim of this study was to define the association between thoracic inlet measures in relation to anterior access to
the cervicothoracic junction.
Methods: Trauma CT scans in patients >16 years were analyzed. The projection angle (PA), defined as the angle subtended by a
line along the superior endplate of the vertebral body and the line from the anterosuperior corner of the vertebral body to the
manubrium, was measured at C7, T1 and T2; angles were positive if the projection was above the manubrium. Thoracic inlet angle
(TIA), thoracic inlet distance (TID) and pelvic incidence (PI) were measured.
Results: 65 scans were assessed (33 males; mean age 47.7 years (s.d. 8.7)). The mean TIA 79.9 (s.d. 13.4 ; range 52.6 – 112.2 ),
mean TID 66.1 mm (s.d. 6.6 mm) and mean PI was 50.5 (s.d. 10.2 ). Mean values for the projection angles at C7, T1 and T2 were
24.2 , 7.6 and 8.3 respectively. PA were positive in 95% at C7, 73% at T1 and 30% at T2. PA at each level correlated sig-
nificantly with age (mean r¼0.371; P ¼ .015) and TIA (mean r¼0.916; P < .001) but neither TID nor PI. TIA correlated with age
(r ¼ 0.328; P ¼ .008).
Conclusions: The projection angles of the CTJ vertebrae are influenced by thoracic inlet angle and a lesser degree age.
Understanding sagittal spinal parameters in the CTJ can aid in planning surgical strategy and approach.

Keywords
imaging, thoracic inlet, cervicothoracic junction, projection angle, anterior access

Introduction cervical spine alignment.7-9 The TIA is generally considered

Anterior surgical approaches to the cervical spine are fre-
quently utilized for a variety of pathology including degenera-
tive, traumatic, infectious and oncologic etiologies. 1,2
However, when an anterior approach to the cervicothoracic
junction is required access may be more challenging as the
medial clavicle and sternum may impede a direct approach –
this may necessitate the use of an osteotomy.3-5
During surgical planning sagittal spinal parameters are often
considered to guide appropriate reconstruction including main-
tenance or restoration of patient-specific alignment. In the cer-
vical spine the Thoracic Inlet Angle (TIA) may be used.6
Defined as the angle subtended by a line drawn perpendicular
to the superior end plate of the T1 vertebral body and a line
drawn through the midpoint of the T1 vertebral body superior
endplate to the manubrium, the TIA can be used to estimate
analogous to the Pelvic Incidence (PI) used for determining ideal
lordosis in the lumbar spine.9
The PI has recently been shown to correlate with the ‘projec-
tion angle’ of the sacral endplate with respect to the pelvis and
predict ease of anterior access to the lumbosacral disc – in this
case a PI over 73 suggests the trajectory of the sacral endplate is
distal to the apex of the pubic symphysis.10 It is intuitive
1
Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New
Zealand.
2
Department of Surgery, University of Auckland, Auckland, New Zealand.
Corresponding Author:
Joseph F. Baker, Department of Orthopaedic Surgery, Waikato Hospital,
Pembroke Street, Hamilton 3204, New Zealand.
Email: joseph.f.baker@gmail.com

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706
Figure 1. Thoracic Inlet Angle (TIA) is measured by the angle (a)
subtended by a line from the midpoint of the superior endplate of T1
through the apex of the manubrium and a line drawn perpendicular
through the center of the superior endplate of T1. The TID is the
distance in millimeters from the midpoint of the superior endplate of
T1 to the apex of the manubrium (y).
therefore that a relationship may exist also between the TIA and
access to the vertebrae at the base of the subaxial spine and
across the cervicothoracic junction.
The aim of this study was to report on the correlation
between sagittal thoracic inlet measures and anterior access
to the cervicothoracic junction as indicated by the ‘projection
angle’. The findings from this study may serve as an aide to
surgeons when considering surgical strategy for pathology at
the cervicothoracic junction.
Materials and Methods
Approval for this study was granted by the Health and Disabil-
ity Ethics Committee (Ref: 20/STH/143). Patient consent was
not required for this study.
Computed tomography (CT) scans performed for the pur-
poses of major trauma assessment were obtained from the
hospital radiology database. Scans were included from
patients aged 16 years to eliminate the potential influence
of skeletal immaturity. Scans were excluded if there was dis-
ease that prevented measurement of sagittal measures (e.g.,
fracture, tumor, trauma, spinal deformity such as spondylo-
listhesis or scoliosis, prior surgery), if there was an abnormal
vertebral body count or if there was transitional anatomy
present. All radiologic assessments were made using Intelli-
Space PACS Enterprise (Koninklijke Philips N.V.) by a single
fellowship-trained spine surgeon.
Patient details including age and sex were recorded. Thor-
acic inlet measures including the Thoracic Inlet Angle (TIA)
Global Spine Journal 13(3)
Figure 2. Pelvic Incidence (PI) is measured by identifying the center of
the femoral heads on the relevant sagittal images (circles) then the
midpoint between these identified on the midsagittal image to define
the bicoxofemoral axis. PI is the angle then subtended by a line from
the bicoxofemoral axis to the middle of the sacral endplate and a line
drawn perpendicular through the center of the sacral endplate.
and Thoracic Inlet Distance (TID) have been well-described in
previous reports including assessment on advanced imaging
modalities.6,7,9,11-14 Measurement of TIA and TID utilized the
midsagittal CT image – clear visualization of the manubrium
was essential to allow the thoracic inlet measures (Figure 1).
Pelvic Incidence (PI) was measured, as has been previously
described, by identifying the midpoint of both femoral heads
to determine the bicoxofemoral axis, then measuring the angle
subtended by a line from the bicoxofemoral axis to the center of
the sacral endplate and a line perpendicular to the center of the
sacral endplate (Figure 2).9,10 The Projection Angle (PA) was
measured at C7, T1 and T2. The PA is defined as the angle
subtended by a line along the superior endplate of the vertebral
body and the line from the anterosuperior corner of the verteb-
ral body to the manubrium. A positive angle, indicating poten-
tial access, is one with projection of the line along the endplate
superior to the manubrium (Figure 3). A negative angle, indi-
cating poor or impossible access, is one with projection inferior
to the manubrium (Figure 4).
All scans, and therefore measures, were taken in the supine
position - it has been shown that the change in thoracic inlet
measures between standing and supine positions is negligible
and so erect imaging has not been used to complement the CT
measures.6,11,13 Further it is established that the manubrium is
poorly visualized on plain radiography and therefore poorly
reliable as a point of measure compared to CT.11,13-15
Baker 707

Table 1. Mean, Standard Deviation and Range of Recorded Values

(Tia: Thoracic Inlet Angle; Tid: Thoracic Inlet Distance; Pi: Pelvic
Incidence; C7pa: C7 Projection Angle; T1pa: T1 Projection Angle;
T2pa: T2 Projection Angle).

Mean S.D. Range

Age (years) 46.9 18.7 16–88

TIA 79.4 13.4 52.6 –112.2
TID (mm) 65.9 6.6 52–83
PI 50.6 10.2 33 –78
C7PA 24.8 14.0 16.7 –51.1
T1PA 8.1 14.6 32.3 –38
T2PA -8.0 14.1 32.5 –23

Intraobserver reliability was assessed using Cronbach’s alpha.

This was completed by performing a second random set of ten
measurements in a blinded-fashion 6 weeks after the first. Pear-
son correlation analysis was used to explore association between
the sagittal variables and projection angles. Linear regression
analysis was used to analyze significant determinants.

Figure 3. A positive projection angle is demonstrated for C7 with the
plane of the superior endplate projecting proximal to the manubrium.
Results
65 scans were analyzed (33 male). The mean age was 47.2
years (s.d. 18.7; range 16-88 years).
Mean values for the thoracic inlet dimensions, pelvic inci-
dence and projection angles are shown in Table 1. There were
no differences in variables between male and female subjects.
Cronbach’s alpha showed excellent reliability for all mea-
sures: TIA (0.958), TID (0.987), C7PA (0.971), T1PA (0.944)
and T2PA (0.977).
Positive projection angles, that is projection above the man-
ubrium, were present in 95% at C7, 73% at T1 and 30% at T2.
Results from the Pearson correlation analysis are shown in
Table 2. Age correlated significantly with both thoracic inlet
measures and all projection angles albeit only mildly so. The
TIA however correlated strongly with all projection angles.
The TID correlated mildly with only the C7PA. Scatterplots
for PA against TIA are shown in Figures 6–8.
Linear regression was performed using both age and TIA
providing the following models:
C7PA ¼ 100 :0  0 :1 x Age  0 :9 x TIA

T1PA ¼ 90 :9  0 :07 x Age  1 :0 x TIA

T2PA ¼ 67 :9  0 :005 x Age  1 :0 x TIA

Figure 4. A negative projection angle is depicted for T2 with the plane
of the superior endplate projecting distal to the apex of the manubrium.
Statistical Analysis
All data was compiled with a Microsoft Excel spreadsheet.
ExcelSTAT was used for statistical analysis. Mean, standard
deviation and range are reported where applicable. Univariate
analysis was performed with the Mann-Whitney U-test.
Discussion
Anterior access to the cervicothoracic junction may be needed to
treat a range of pathology.1,2 Degenerative disease, trauma,
infection or tumor resulting in loss of structural integrity of the
anterior column may necessitate anterior access; compression of
the spinal cord from anterior column pathology such as meta-
static disease or extradural disease may be better managed via an
anterior approach to adequately and safely decompress the spinal
 708

Table 2. Results from Pearson Correlation Analysis, Statistically Significant Results (P < .05) Are Shown In Bold. R-Values, 95% Confidence Intervals And P-Values (Italics) Are Shown. Pi:
Pelvic Incidence; Tia: Thoracic Inlet Angle; Tied: Thoracic Inlet Distance; C7pa: C7 Projection Angle; T1pa: T1 Projection Angle; T2pa: T2 Projection Angle.

Variables Gender Age PI TIA TID C7PA T1PA T2PA

Gender 1 0.068 0.159 0.132 0.066 0.003 00.054 0.147

0.180–0.309 0.090–0.390 0.366–0.118 0.307–0.182 0.243–0.249 0.194–0.296 0.103–0.379
0.591 0.209 0.299 0.602 0.981 0.670 0.247
Age 0.068 1 0.062 0.328 0.344 ⴚ0.414 ⴚ0.396 ⴚ0.304
0.180–0.309 0.187–0.303 0.090–0.531 0.107–0.544 ⴚ0.599– ⴚ0.187 ⴚ0.585– ⴚ0.166 ⴚ0.512– ⴚ0.063
0.591 0.627 0.008 0.005 0.001 0.001 0.005
PI 0.159 0.062 1 0.105 0.007 0.031 0.007 0.041
0.090–0.390 0.187–0.303 0.144–0.342 0.252–0.239 0.217–0.274 0.253–0.239 0.284–0.207
0.209 0.627 0.408 0.957 0.811 0.954 0.745
TIA 0.132 0.328 0.105 1 0.067 ⴚ0.894 ⴚ0.949 ⴚ0.906
0.366–0.118 0.090–0.531 0.144–0.342 0.182–0.307 ⴚ0.935– ⴚ0.831 ⴚ0.969– ⴚ0.918 ⴚ0.942– ⴚ0.849
0.299 0.008 0.408 0.601 <0.0001 <0.0001 <0.0001
TID 0.066 0.344 0.007 0.067 1 ⴚ0.268 0.147 0.007
0.307–0.182 0.107–0.544 0.252–0.239 0.182–0.307 ⴚ0.482– ⴚ0.024 0.379–0.103 0.253–0.239
0.602 0.005 0.957 0.601 0.032 0.247 0.954
C7PA 0.003 ⴚ0.414 0.031 ⴚ0.894 ⴚ0.268 1 0.949 0.800
0.243–0.249 ⴚ0.599– ⴚ0.187 0.217–0.274 ⴚ0.935– ⴚ0.831 ⴚ0.482– ⴚ0.024 0.917–0.969 0.690–0.946
0.981 0.001 0.811 <0.0001 0.032 <0.0001 <0.0001
T1PA 0.054 ⴚ0.396 0.007 ⴚ0.949 0.147 0.949 1 0.913
0.194–0.296 ⴚ0.585– ⴚ0.166 0.253–0.239 ⴚ0.969– ⴚ0.918 0.379–0.103 0.917–0.969 0.860–0.946
0.670 0.001 0.954 <0.0001 0.247 <0.0001 <0.0001
T2PA 0.147 ⴚ0.304 0.041 ⴚ0.906 0.007 0.800 0.913 1
0.103–0.379 ⴚ0.512– ⴚ0.063 0.284–0.207 ⴚ0.942– ⴚ0.849 0.253–0.239 0.690–0.946 0.860–0.946
0.247 0.005 0.745 <0.0001 0.954 <0.0001 <0.0001
Global Spine Journal 13(3)
Baker
Figure 5. Comparison of strongly positive projection angle at C7 in a younger patient (A) against a strongly negative angle at C7 in an elderly
patient (B).
cord than via a posterior approach that can be technically chal-
lenging at the cervicothoracic junction.16-18 Analysis of individ-
ual anatomy and assessment of potential access is essential to
reduce morbidity and achieve surgical goals.
The aim of this study was therefore to determine the rela-
tionship of sagittal thoracic inlet measures, principally the TIA,
and anterior access to the cervicothoracic junction. Although
age correlated with the projection angle of the vertebrae, this
was only mild. The main determinant of anterior access was the
TIA evidenced by a strong correlation with the projection angle
in each instance. The projection angle of the superior endplate
of the vertebrae correlated strongly with the TIA in a similar
fashion to previous work demonstrating the projection angle of
the lumbosacral disc in relation to the PI.10 In the previous
work it was evident that once the PI is over 70 then anterior
access to the lumbosacral disc becomes difficult if not a sub-
optimal strategy.
In this current study it is notable that the projection angle
from T2 was positive in almost one third of cases indicating
potential access without osteotomy - the projection angle for
C7 tended to become negative only once the TIA was above
105 while for T2 the PA only tended toward negative once the
TIA was above 70 . As our understanding of the role of TIA in
determining cervical alignment improves, its role in surgical
planning, much like the PI in lumbar surgery, should be further
elucidated. Noting that there is a likely threshold beyond which
anterior access to the CTJ becomes difficult is a key component
of sound surgical planning. However, it is worth noting that
when accessing the disc space only, a narrow corridor could
still be encountered and access to the posteroinferior corner of
T1 would remain challenging. Some surgeons may consider the
medial border of the clavicle as the limiting anatomic structure
rather than the manubrium - this study was performed in a
manner consistent with other reports that have considered the
manubrium as the inferior limit of the surgical corridor.1,2,19
709
Complex spine surgery frequently involves advanced ima-
ging modalities for planning and measurement of the projection
angle and thoracic inlet parameters can aid in determining the
best strategy for surgical access including consideration of
osteotomy where needed. Incorporating the findings relating
access to sagittal plane parameters into planning software may
be an option.20 Additionally, anticipating that anterior access to
the CTJ may be difficult will allow the surgeon to ensure
appropriate instruments, such as angled or articulted devices,
are available.
Similar to this current study, Karikari et al. previously
assessed the potential to access the disc space anteriorly across
the cervicothoracic junction also using computed tomography.1
The T1/2 level was most commonly the most caudad level
accessible (46%) and the T2/3 to a lesser degree (20%). How-
ever, the relationship between access and sagittal plane para-
meters not explored. Mai et al. analyzed sagittal MRI imaging
to determine the most caudad level accessible and noted that in
83% this was the T1/2 disc — approximately 10% more than in
the current study.15 Reasons for this difference may be related
to imaging modality or body habitus but again sagittal plane
parameters were not analyzed. Finally, analysis of supine MRI
by Lakshamanan et al. utilized a line tangential to the manu-
brium to determine the most caudad level accessible via an
anterior approach.2 Although in nearly 70% of cases this line
passed through T2 or T3, this assessment of imaging is more
applicable when planning a corpectomy is required as the
visualization is improved with removal of bone.
There was a weak correlation between age and the TIA. The
inlet may change with age as the thoracic cavity dimensions
change and therefore the ‘base’ upon which the cervical spine
sits also changes. However, the influence of age on the projec-
tion angle was near negligible in the regression analysis. A
more pronounced or protruded sternum, a factor of thoracic
cavity morphometry, may additionally influence ease of access
710 Global Spine Journal 13(3)

Figure 6. Scatterplot of C7PA (y) against TIA (x) with linear regression equation.

Figure 7. Scatterplot of T1PA (y) against TIA (x) with linear regression equation.

and this factor has not been assess in this current study.
Extremes of PA are shown in Figure 5 where it is evident how
the disc may be more easily accessed in the scan on the left
compared to that shown on the right.
Limitations of this study include use of computed tomogra-
phy alone in the supine position, although we note that the TIA
does not appear to change between supine and standing pos-
tures. 11 However, any surgical procedure is likely to be
performed in a position not dissimilar to that in which these
scans were obtained with the cervical spine in extension to
accentuate surgical access. There is also potential for spinal
alignment, and therefore the thoracic inlet angle, to change
with respiration although this is thought likely to be only mild
without aggressive inspiration or expiration.21,22 To define the
influence of patient positioning, flexing or extending the spine,
application of traction - both through cervical tongs and taping
Baker
Figure 8. Scatterplot of T2PA (y) against TIA (x) with linear regression equation.
or depressing the shoulders, and respiratory status on thoracic
inlet parameters and the anterior access to the CTJ, intra-
operative 3-dimensional imaging could be utilized. However,
this would confer additional radiation exposure and raises ethi-
cal questions about unnecessary patient risk.
This study also only analyzes patients without overt disease
of the spinal column accepting that CT is not the diagnostic tool
of choice to define disc disease. Although normative data is
often useful, application of the findings of this study to the
deformed spine may not be immediately appropriate – one needs
to consider that a deformed spine may be stiff, perhaps in the
setting of post-traumatic deformity, or flexible, perhaps arising
from acute pathologic fracture secondary to metastatic disease.
The findings from this study may have more ready application
to the latter but the degree of correction may only be evident
when the patient is fully anesthetized and traction applied.
Furthermore, while this study defines the osseous structures
that may impede access to the cervicothoracic junction, the
complex vascular and neurologic anatomy present in the
thoracic inlet must also be studied in detail on advanced imag-
ing and it may be the need for protection of these structures that
dictates the need for manubrial or sternal osteotomy although
various corridors have been described to facilitate safe passage
past the major structures to gain access to the CTJ.23,24
In conclusion, a strong negative correlation between the
Thoracic Inlet Angle and the Projection Angle of the cervi-
cothoracic vertebrae was found and the influence of age on
anterior access appears only minor. As the TIA approaches
105 , access to C7/T1 may become more challenging. During
surgical planning attention to the sagittal thoracic inlet mea-
sures can help guide not only alignment goals but also access
711
strategy when an anterior approach to the cervicothoracic junc-
tion is desired.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Joseph F. Baker, MCh, FRCSI https://orcid.org/0000-0002-8518-8780
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