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Growth and Development of the Pediatric Cervical Spine Documented

Radiographically
Jeffrey C. Wang, Stephen L. Nuccion, John E. Feighan, Brad Cohen, Frederick J. Dorey and Peter V. Scoles
J Bone Joint Surg Am. 83:1212-1218, 2001.

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COPYRIGHT 2001

BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Growth and Development

of the Pediatric Cervical Spine
Documented Radiographically
BY JEFFREY C. WANG, MD, STEPHEN L. NUCCION, MD, JOHN E. FEIGHAN, MD,
BRAD COHEN, MD, FREDERICK J. DOREY, PHD, AND PETER V. SCOLES, MD
Investigation performed at the Department of Orthopaedic Surgery, University of California at Los Angeles School of Medicine,
Los Angeles, California, and the Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio

Background: The radiographic anatomy of the cervical spine in children is complex and can be difficult to interpret. The present study was undertaken to document radiographically the growth and development of the cervical
spine in a prospective, longitudinal manner and to establish standard radiographic measurements on the basis of
findings in patients who were followed serially from the age of three months until skeletal maturity.
Methods: The radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush
Collection, Cleveland, Ohio) were reviewed. From this large database, we identified fifty boys and forty-six girls
who had a sufficient number of radiographs of the cervical spine for inclusion in our study. With use of a computerized image analyzer, the growth and development of the atlantodens interval, the diameter of the spinal canal,
the Torg ratio, the height and width of the second through fifth cervical vertebral bodies, the height of the dens,
and the ossification of the first cervical vertebra were assessed on serial radiographs made from the age of three
months until skeletal maturity.
Results: Serial measurements of the atlantodens interval, the anteroposterior diameter of the cervical canal, the
height and anteroposterior width of the cervical vertebral bodies, and the height of the dens, made in normal,
healthy children from the age of three months to fifteen years, are presented in tabular and graphic forms. The
median Torg ratio was 1.47 for both males and females primarily, and it reached values of 1.06 for males and
1.10 for females by maturity. The anterior arch of the first cervical vertebra had ossified in 33% of the children by
the age of three months and in 81% of the children by the age of one year. Closure of the synchondroses was
completed in all children by the age of three years.
Conclusions: The measurements presented in the current study are important because they are the first, as far
as we know, to document the radiographic parameters of the cervical spine in children who were followed longitudinally from before the age of three years through the course of growth and development until skeletal maturity.

he radiographic appearance of the pediatric cervical

spine is an important tool for the detection of congenital malformations, neoplasms, and injuries1-7. The
potentially devastating consequences of undiagnosed abnormalities have prompted clinicians in a number of disciplines
to develop guidelines to aid in the interpretation of pediatric
cervical radiographs.
Proper interpretation of radiographs of the immature
cervical spine requires accurate normal standards. Many investigators have calculated norms for the cephalad portion of
the cervical spine in adults with use of radiographic and anatomical techniques8-10. The relationship of the spinal cord to
the osseous structures of the cervical spine is of critical importance. Fractures, dislocations, and subluxations of the neck
may encroach upon the cervical canal and impinge upon the
cord. Although spinal injuries in infants and children are uncommon, they tend to involve the cervical spine more than the
thoracic or lumbar spine and tend to affect the cephalad por-

tion of the cervical spine more than the caudad portion11.

It is clear from previous studies that the diameter of the
cervical spinal canal and the size of the cervical vertebral bodies change differentially with growth. Other investigators have
proposed broad standards for normal canal size in childhood.
Simril and Thurston proposed standards for the thoracic and
lumbar interpedicular spaces in children, but they did not
study the cervical spine because of the difficulty in differentiating the junction of the lamina and the pedicle12. The studies
by Hinck et al.13, Markuske14, and Naik15 have been used as references for the evaluation of patients with developmental,
neoplastic, and traumatic lesions of the cervical spine. Although useful, none of these studies were truly longitudinal.
The advantage of a longitudinal study is that the values are obtained from the same patients as they grow rather than from
different patients at various ages and then averaged. Longitudinal studies result in a more accurate method of assessing
changes in anatomy with growth and development.

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The present radiographic standards for children and adolescents have been established from studies of small groups
of patients1,10,12,13. We are not aware of any previous longitudinal study in which the growth and development of the cervical
spine has been followed from birth to maturity. The purpose
of our study was to document radiographically the growth
and development of the cervical spine in a highly controlled,
longitudinal manner and to establish standard radiographic
measurements for the pediatric cervical spine. We assessed the
atlantodens interval, the canal diameter, the Torg ratio, the
height and width of the second through fifth cervical vertebral
bodies, the height of the dens, and the ossification of the anterior arch of the first cervical vertebra in patients from the age
of three months until skeletal maturity16.
Materials and Methods
he radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush Collection,
Cleveland, Ohio) were reviewed. The collection was compiled
from 1927 to 1942 and includes data only from healthy children with no evidence of congenital, neurological, or developmental disease who were evaluated at regular intervals from
the age of three months until skeletal maturity17,18. Approximately 3000 children participated in the overall study. The
Gruelich and Pyle atlases of skeletal maturation of the hand,
wrist, and knee were developed from this database19.
Approximately 200 children participated in the radiographic evaluation of the cervical spine. Each subject was to
have a plain lateral radiograph of the cranium and the cervical
spine made at the ages of three, six, nine, twelve, eighteen,
twenty-four, thirty, thirty-six, forty-two, forty-eight, fifty-four,
and sixty months and then annually until the age of seventeen
years. A standard tube-to-film distance was used with a filmto-focal spot distance of approximately 72 in (183 cm). The
head was immobilized in a rigid frame during the exposures.
Fifty boys and forty-six girls had a sufficient number of radiographs of the cervical spine for inclusion in the present study.
This group was considered to be eligible for our study on the
basis of the clarity of the radiographs and the availability of
studies that had been made until skeletal maturity. Radiographs were considered to be suboptimal if they were blurred
by motion or if any of the osseous structures were obscured by
the head-holder; suboptimal studies were not included in the
analysis. Additionally, not every child had each scheduled radiograph. However, radiographs were available for a total of
more than seventy-five subjects at each time-point before the
age of twelve years. More than one-half of the subjects had radiographs made until the age of fourteen years, and approximately one-third of the subjects had radiographs made until
the age of seventeen years.
The outline of the cervical spine on each radiograph was
traced onto a transparent sheet. Examples of some of the measured variables are shown in Figure 1. As the radiographs
frequently did not include the sixth and seventh cervical vertebrae, these levels were not included in the measurements.
Vertical lines were placed along the most anterior and poste-

G ROW T H A N D D E VE L O P M E N T O F T H E P E D I A T R I C
CER V ICAL SPINE DOCUMENTED RADIOGRAPHICALLY

rior points of the vertebral bodies and along the most anterior point of the posterior arches, along the posterior portion
of the anterior aspect of the atlas, and along the anterior portion of the dens. Horizontal lines were placed along the most
superior and inferior portions of the vertebral bodies. Images
were entered into a computer with use of a SummaSketch
Plus digitizing pad (SummaGraphics, GTCO CalComp, Scottsdale, Arizona). The images were analyzed with use of a customdesigned software program written in Turbo Basic.
The atlantodens interval was measured as the distance
between the posterior aspect of the anterior arch of the first
cervical vertebra and the anterior aspect of the dens in the anteroposterior direction. The sagittal diameter of the canal at
the second cervical level was measured from the most anterior
aspect of the posterior arch of that vertebra to the posterior
aspect of the dens at the same level on a horizontal line in the
anteroposterior direction on the lateral radiograph. For the
third, fourth, and fifth cervical vertebrae, the sagittal diameter of the canal was measured from the most anterior portion
of the posterior arch to the center of the posterior aspect of the
corresponding vertebral body along the anteroposterior plane.
The Torg ratio was also calculated, in the fashion originally
described by Torg, by dividing the value for the sagittal diameter of the canal at the fifth cervical level by the anteroposterior
diameter of the vertebral body16. The width of the second,
third, fourth, and fifth cervical vertebral bodies was measured
at the midpoint of the posterior aspect of each vertebral body.
The vertical height was measured at both the anterior and

Fig. 1

Diagram of the method that was used to measure the variables that
were examined. The diagram on the left shows the tracing of the cephalad part of the cervical spine. The diagram on the right demonstrates
some, but not all, of the variables that were measured. A = width of the
dens, B = sagittal diameter of the canal at the first cervical level, C =
width of the second cervical vertebra, D = sagittal diameter of the
canal at the second cervical level, E = sagittal diameter of the third
cervical vertebral body, F = sagittal diameter of the canal at the third
cervical level, and G = height of the fourth cervical vertebra.

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TABLE I

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CER V ICAL SPINE DOCUMENTED RADIOGRAPHICALLY

Data on the Atlantodens Interval and the Canal Diameters According to Gender and Age*
Male
Variable

Female

0-60 mo

61-120 mo

2.02 (0.40)

2.16 (0.57)

2.19 (0.67)

2.16 (0.96)

1.91 (0.51)

1.83 (0.64)

Second cervical level

15.63 (1.01)

17.89 (1.19)

18.22 (1.35)

14.73 (1.21)

17.02 (1.39)

17.42 (1.63)

Third cervical level

Fourth cervical level

13.92 (0.88)
13.51 (0.84)

15.55 (1.19)
15.06 (1.09)

15.76 (1.34)
15.37 (1.28)

13.30 (0.98)
13.00 (0.92)

14.93 (1.08)
14.64 (0.99)

15.44 (1.20)
14.93 (1.35)

Fifth cervical level

13.79 (0.89)

14.98 (1.03)

15.22 (1.41)

13.41 (1.21)

14.79 (1.00)

14.82 (1.29)

Atlantodens interval (mm)

121-180 mo

0-60 mo

61-120 mo

121-180 mo

Diameter of canal (mm)

*The values are given as the median, with the standard deviation in parentheses.

posterior portions of these vertebral bodies. The average of the

anterior and posterior heights for each vertebral body was
used to calculate the height of the individual vertebra. The
height of the second cervical vertebra was measured from the
inferior aspect of the vertebral body to the tip of the dens. The
height of the dens itself was measured from the tip of the dens
to the synchondrosis. All measurements were recorded in millimeters, and individual plots were made for each subject.
Once all of the measurements had been made, they were
analyzed in the following statistical fashion. For each variable
x, a quadratic polynomial equation with the formula y = a +
bx + cx2 was solved with use of linear regression for each individual. The predicted value at each time-point for each individual was used to calculate the distribution of measurements
for each time-period. The tenth percentile, median, and ninetieth percentile values were subsequently calculated at each
time-point and graphed over time. The data were also summarized by calculating, separately for males and females, the
median value and the standard deviation for three different
age-groups (zero to sixty months, sixty-one to 120 months,
and 121 to 180 months).
TABLE II

Results
he study began with forty-six female subjects and fifty
male subjects. Some radiographs could not be included in
the study for technical reasons, and some subjects were lost to
follow-up as the study progressed. The sample size for the
male and female subjects who had radiographs that could be
measured remained fairly constant until a gradual attrition of
subjects began at the age of ten years and continued until the
age of seventeen years. Forty-four (96%) of the original fortysix female subjects and forty-seven (94%) of the original fifty
male subjects had radiographs made until the age of ten years.
Only twenty-one female subjects and seventeen male subjects
were followed for more than fifteen years. There was equal
representation of both boys and girls at all time-points. The
results are presented in Tables I and II.

The Atlantodens Interval

At six months, the median atlantodens interval was 1.97 mm
for boys and 2.01 mm for girls. By 180 months, the median
value had reached 2.45 mm for both boys and girls. A graph of
the results is shown in Figure 2.

Data on the Width and Height of the Cervical Vertebrae According to Gender and Age*
Male
Variable

Female

0-60 mo

61-120 mo

121-180 mo

0-60 mo

61-120 mo

121-180 mo

Second cervical vertebra

10.41 (0.61)

12.88 (0.82)

14.52 (0.98)

9.79 (0.70)

12.49 (0.84)

14.30 (1.02)

Third cervical vertebra

Fourth cervical vertebra

10.36 (0.62)
10.37 (0.62)

12.93 (0.84)
12.76 (1.18)

14.53 (0.97)
14.10 (1.18)

9.74 (0.65)
9.68 (0.69)

12.26 (0.91)
12.11 (0.92)

13.86 (0.95)
13.38 (1.08)

Fifth cervical vertebra

10.57 (0.66)

12.57 (0.95)

13.94 (1.60)

10.05 (0.74)

12.03 (1.24)

13.64 (1.17)

Width (mm)

Height (mm)
Second cervical vertebra

18.79 (5.03)

27.54 (3.26)

33.65 (3.71)

18.92 (5.49)

27.48 (3.09)

34.28 (3.75)

Third cervical vertebra

5.52 (1.18)

7.82 (1.29)

11.51 (2.45)

5.84 (1.18)

8.09 (1.20)

11.56 (2.69)

Fourth cervical vertebra

5.41 (1.24)

7.77 (1.15)

10.98 (2.12)

5.70 (1.17)

8.01 (1.24)

11.27 (2.43)

Fifth cervical vertebra

5.47 (1.19)

7.53 (0.99)

10.51 (2.10)

5.74 (1.12)

7.69 (1.10)

10.79 (2.16)

*The values are given as the median, with the standard deviation in parentheses.

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Fig. 2

Values (in millimeters) for the tenth

percentile, the median, and the
ninetieth percentile for the atlantodens interval (ADI), graphed continuously over time.

Canal Diameter
In male subjects, the median canal diameter at the second cervical level increased from 12.79 mm at six months to 16.00 mm
by 156 months and remained constant thereafter. In female
subjects, the median canal diameter at the second cervical level
increased from 12.27 mm at six months to 15.75 mm by 168
months. A graph of the results is shown in Figure 3. The canal
diameters at the third and fourth cervical levels were nearly
identical in terms of both dimension and rate of change. In
male subjects, the median canal diameter increased from 12.33
mm initially to 15.54 mm by maturity. In female subjects, the
median canal diameter at these levels increased from 11.76 mm
to 15.31 mm. In male subjects, the median canal diameter at the
fifth cervical level increased from 12.74 mm to 15.67 mm, and
in female subjects, it increased from 12.26 mm to 15.22 mm.
Torg Ratio
The median Torg ratio (the ratio of the canal diameter to the
vertebral body diameter) at the fifth cervical level was 1.47
(tenth to ninetieth percentile, 1.26 to 1.64) at three months
and 1.06 (0.81 to 1.33) by maturity for male subjects and 1.47
(1.04 to 1.75) and 1.10 (0.88 to 1.20), respectively, for female
subjects. A graph of the results is shown in Figure 4.
Width of the Cervical Vertebral Bodies
The median width of the second cervical vertebral body increased from 9.13 mm initially to 15.15 mm by maturity for
male subjects and from 8.40 mm to 14.90 mm for female sub-

jects. The median width of the third cervical vertebral body

increased from 9.04 mm to 14.64 mm for males and from 8.38
mm to 14.12 mm for females. The median width of the fourth
cervical vertebral body increased from 9.28 mm to 14.60 mm
for males and from 8.48 mm to 13.87 mm for females. The
median width of the fifth cervical vertebral body increased
from 9.47 mm to 14.44 mm for males and from 8.96 mm to
13.81 mm for females.
Height of the Cervical Vertebral Bodies
The median height of the second cervical vertebral body was
14.51 mm initially and 35.54 mm by maturity for males and
14.05 mm and 34.29 mm, respectively, for females. A graph of
the results is shown in Figure 5. The median height of the
third cervical vertebra increased from 4.68 mm to 13.94 mm
for males and from 5.10 mm to 12.23 mm for females. The
median height of the fourth cervical vertebra increased from
4.45 mm to 12.89 mm for males and from 4.69 mm to 11.69
mm for females. The median height of the fifth cervical vertebra increased from 4.47 mm to 12.47 mm for males and from
4.89 mm to 11.17 mm for females.
Height of the Dens
The initial median height of the dens was 5.78 mm (tenth to
ninetieth percentile, 5.21 to 6.85) for males and 5.66 mm (4.96
to 6.68) for females. By maturity, the dens had attained a median height of 10.35 mm (9.33 to 11.77) for males and 10.61
mm (9.21 to 12.23) for females.

Fig. 3

Values (in millimeters) for the tenth

percentile, the median, and the ninetieth percentile for the sagittal diameter of the canal at the second
cervical level, graphed continuously
over time.

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Fig. 4

Values for the tenth percentile,

the median, and the ninetieth percentile for the Torg ratio, graphed
continuously over time.

Fig. 5

Values (in millimeters) for the tenth

percentile, the median, and the
ninetieth percentile for the height
of the body of the second cervical
vertebra, graphed continuously over
time.

Ossification of the First Cervical Vertebra

The anterior arch had ossified in 33% of the children by three
months and in 81% of the children by one year. Ossification
was complete in all children by three years of age.
Discussion
tandard values have been proposed in the literature for the
atlantodens interval, the contour of the odontoid process,
the width of the spinal canal at each cervical level, the proportion of the canal occupied by the dens at the first cervical level,
and the ratio of the cervical canal to the width of the vertebral
body (the Torg ratio)1,2,4,8-11,13-15,20. The standard values were based
on studies involving a review of the radiographs of the cervical
spine of neurologically normal adults or on small studies of
cadavera.
The studies by Markuske14, Hinck et al.13, and Naik15 in
particular have been used as references for the evaluation of
patients with developmental, neoplastic, and traumatic lesions of the cervical spine. Although useful, these studies were
not truly longitudinal and provide only limited information
about the growth of the pediatric cervical spine.
Markuske measured the sagittal diameter of the cervical
canal in three groups of forty patients each who were stratified
according to age (three to six years old, seven to ten years old,
or eleven to fourteen years old)14. In addition to providing the
mean diameter (and standard deviation) of the canal for each
group, he standardized the relationship between the diameter
of the canal and the height of the patient (in 10-cm increments) for the entire sample population. His findings showed a
slight increase in sagittal diameter at each vertebral level as the
patients increased in both height and age. Markuskes study,

however, was not longitudinal. Furthermore, the increase in the

diameter of the cervical canal from the three to six-year-old
age-group to the eleven to fourteen-year-old age-group was
within the standard deviation for both groups. Markuske did
not investigate the diameter of the canal in infants, and his
findings cannot be used as standards for children who are less
than three years old, a group that is characterized by substantial growth and development.
Hinck et al. attempted to study the longitudinal development of the cervical canal over a ten-year period in patients
who were three years of age and older13. They proposed reference standards for the first through the fifth cervical vertebra.
Unfortunately, none of the patients were followed for the full
ten-year period. In addition, the study only included patients
who had reached the age of three years, by which time the majority of changes in the cervical spine have already occurred.
Naik proposed a method for calculating the sagittal diameter of the cervical spinal canal in infants, which can be difficult because of the cartilaginous nature of the lamina
posteriorly15. Measurements on twenty-five radiographs were
compared with findings on eleven postmortem dissections of
the cervical spine. The measurements were found to be within
2 mm of each other. However, neither standard deviations nor
the ages of the subjects were noted in that study. Additionally,
the sample size was quite small.
Locke et al. studied 200 children of various ages to construct standards for the atlantodens interval in the asymptomatic child20. Although Locke et al. contributed valuable
information, their study differs from the present study in several regards. They studied children of various ages at a single
time-point, whereas we examined children on a longitudinal

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basis. Their patients were at least three years old, whereas our
patients were followed beginning at the age of three months.
Additionally, Locke et al. measured only the atlantodens interval, whereas we evaluated a wide variety of radiographic dimensions of the cervical spine in the growing child. The
atlantodens interval is a radiographic representation of the relationship between the posterior aspect of the anterior arch of
the first cervical vertebra and the anterior aspect of the odontoid process. The normal value suggests that the transverse ligament and the other check ligaments are still functional.
A standard set of normal values for the cervical vertebral
bodies has not been published in the literature. Very few, if
any, investigators have even attempted to examine the growth
and development of the pediatric cervical vertebral body1.
Most investigators have concentrated on depicting standard
values for the cervical canal14,15. Swischuk et al. examined the
lateral radiographs of the cervical spine of 481 pediatric patients to assess the configuration of the vertebral bodies21.
Their findings demonstrated that cervical vertebral bodies are
oval early in infancy and become more rectangular as maturation proceeds. That study was not longitudinal. The authors
also did not attempt to provide numerical values for the vertebrae as they developed.
It is important to note that the current study is an examination of radiographic manifestations and measurements of
development and applies only to the portion of the skeleton
that has transformed into bone.
To our knowledge, the present investigation is the first
prospective, highly controlled study in which the growth and
development of the cervical spine was assessed in a longitudinal manner from the age of three months to skeletal maturity.
We found that the cervical canal grows rapidly during the first
three years of life, by which time it has reached nearly 95% of
its mature diameter. The increase in the height of the third,
fourth, and fifth vertebral bodies was linear from the age of six
months to maturity, but the growth of the second cervical vertebra was most rapid in the first five years of life and became
linear thereafter. This appears to be a function of the increasing height of the dens, and it may be an artifact of the ossification of the superior portion of the dens. Our findings indicate
that the vertebral bodies grow rapidly during the first five
years of life and then continue to grow at a slower rate until

G ROW T H A N D D E VE L O P M E N T O F T H E P E D I A T R I C
CER V ICAL SPINE DOCUMENTED RADIOGRAPHICALLY

maturity. The normal dimensions of the developing spine that

are documented in the present study can be used as reliable
growth standards for female and male children. Clinical comparisons can be made to assess a patient with regard to age, the
potential further development of the cervical spine, and the
radiographic standards for the anatomical structures.
Appendix
The present study was performed in an attempt to establish normal values for the cervical canal, atlantodens interval, Torg ratio, and height and width of the cervical vertebral
bodies in the pediatric population. Although the growth patterns and development of the cervical spine are reported, complete presentation of all of the data demonstrating all of the
values, norms, and percentiles for the all of the measurements
according to the ages of the patients is beyond the scope of this
single article. These data have been calculated and sorted into
multiple graphs according to gender and age and are available
with the electronic versions of this article, on our web site
(www.jbjs.org) and on our CD-ROM (call 781-449-9780, ext.
140, to order).

Jeffrey C. Wang, MD
Stephen L. Nuccion, MD
Frederick J. Dorey, PhD
Department of Orthopaedic Surgery, University of California at Los
Angeles School of Medicine, Box 956902, Los Angeles, CA 90095-6902
John E. Feighan, MD
Brad Cohen, MD
Department of Orthopaedic Surgery, Case Western Reserve University,
11100 Euclid Avenue, Cleveland, OH 44106
Peter V. Scoles, MD
National Board of Medical Examiners, 3750 Market Street, Philadelphia,
PA 19104-3190
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit
organization with which the authors are affiliated or associated.

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