title: Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group.
abstract: OBJECTIVE
  Upper cervical spine injuries in the pediatric age group have been recognized as extremely unstable from ligamentous disruption and as potentially lethal. Few measurement norms have been published for the pediatric upper cervical spine to help diagnose this pathological state. Instead, adult measurement techniques and results are usually applied inappropriately to children. The authors propose using high-resolution reconstructed CT scans to define a range of normal for a collection of selected upper cervical spine measurements in the pediatric age group.
  
  
  METHODS
  Sagittal and coronal reformatted images were obtained from thin axial CT scans obtained in 42 children (< 18 years) in a 2-month period. There were 25 boys and 17 girls. The mean age was 100.9 months (range 1-214 months). Six CT scans were obtained for nontrauma indications, and 36 were obtained as part of a trauma protocol and later cleared for cervical spine injury. Six straightforward and direct linear distances-basion-dental interval (BDI); atlantodental interval (ADI); posterior atlantodental interval (PADI); right and left lateral mass interval (LMI); right and left craniocervical interval (CCI); and prevertebral soft-tissue thickness at C-2-that minimized logistical and technical distortions were measured and recorded. Statistical analysis including interobserver agreement, age stratification, and sex differences was performed for each of the 6 measurements.
  
  
  RESULTS
  The mean ADI was 2.25 ± 0.24 mm (± SD), the mean PADI was 18.3 ± 0.07 mm, the mean BDI was 7.28 ± 0.10 mm, and the mean prevertebral soft tissue width at C-2 was 4.45 ± 0.43 mm. The overall mean CCI was 2.38 ± 0.44 mm, and the overall mean LMI was 2.91 ± 0.49 mm. Linear regression analysis demonstrated statistically significant age effects for PADI (increased 0.02 mm/month), BDI (decreased 0.02 mm/month), and CCI (decreased 0.01 mm/month). Similarly significant effects were found for sex; females demonstrated on average a smaller CCI by 0.26 mm and a smaller PADI by 2.12 mm. Moderate to high interrater reliability was demonstrated across all parameters.
  
  
  CONCLUSIONS
  Age-dependent and age-independent normal CT measurements of the upper cervical spine will help to differentiate physiological and pathological states in children. The BDI appears to change significantly with age but not sex; on the other hand, the LMI and ADI appear to be age-independent measures. This preliminary study suggests acceptable levels of interrater reliability, and further expanded study will aim to validate these measurements to produce a profile of normal upper cervical spine measurements in children.
authors.affiliation: Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada ; and.
authors.forename: Shobhan
authors.initials: S
authors.lastname: Vachhrajani
authors.forename: Anish N
authors.initials: AN
authors.lastname: Sen
authors.forename: Krishna
authors.initials: K
authors.lastname: Satyan
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.forename: Sherri B
authors.initials: SB
authors.lastname: Birchansky
authors.forename: Andrew
authors.initials: A
authors.lastname: Jea
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002574:Cervical Vertebrae / Q000293:injuries; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D016014:Linear Models; D008297:Male; D015588:Observer Variation; D012016:Reference Values; D015203:Reproducibility of Results; D012737:Sex Factors; D013116:Spinal Cord / Q000000981:diagnostic imaging*; D013124:Spinal Injuries / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed
keywords: ADI = atlantodental interval; BDI = basion-dental interval; CCI = craniocervical interval; CV = coefficient of variation; CVME = CV of the method error; ICC = intraclass coefficient; LMI = lateral mass interval; PADI = posterior ADI; UTL = upper tolerance limit; cervical spine; computed tomography; occipitoatlantoaxial spine; pediatric spine