title: Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle-C1 interval.
abstract: OBJECTIVE
  Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle-C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD.
  
  
  METHODS
  A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines.
  
  
  RESULTS
  The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 ± 16 years (range 19-87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 ± 9.7 years (range 20-56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 ± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 ± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 ± 0.18 mm (range 1.5 mm-6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 ± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively.
  
  
  CONCLUSIONS
  The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Martinez-Del-Campo
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kalb
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Hector
authors.initials: H
authors.lastname: Soriano-Baron
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Jay D
authors.initials: JD
authors.lastname: Turner
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Neal
authors.affiliation: Southern Oregon Neurosurgical and Spine Associates, Medford, Oregon.
authors.forename: Timothy
authors.initials: T
authors.lastname: Uschold
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Theodore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001269:Atlanto-Occipital Joint / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D004204:Joint Dislocations / Q000175:diagnosis / Q000000981:diagnostic imaging*; D007596:Joints / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009777:Occipital Bone / Q000000981:diagnostic imaging*; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000175:diagnosis / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed / Q000379:methods; D055815:Young Adult
keywords: AOD = atlantooccipital dislocation; ASIA = American Spinal Injury Association; BAI = basion axial interval; BDI = basion-dental interval; C-1; CCI = occipital condyle–C1 interval; CVJ = craniovertebral junction; LCCI = left CCI; Oc–C1 = occiput–C1; RCCI = right CCI; ROC = receiver operating characteristic; adults; atlantooccipital; cervical; condyle; dislocation; occipital