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Standardized method for the measurement of Grabb’s line and clival-canal angle

Jonathan E. Martin, Markus Bookland, Douglas Moote, and Catherine Cebulla

M easurement precision is critical to the establishment of a clinically useful radiographic measurement. Since its initial description in 1998, Grabb’s line—the perpendicular distance from the basion-C2 line (pB-C2)—has been adopted by many in the neurosurgical community as a quantifiable measure of ventral brainstem compression. 5 In combination with the work of Menezes, 8 , 9 it has been used to justify occipital-cervical fusion in selected patients. 1 Although generally regarded as easily reproducible, 2 recent attempts to rigorously assess the interrater

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Poor correlation between head circumference and cranial ultrasound findings in premature infants with intraventricular hemorrhage

Clinical article

Martha-Conley E. Ingram, Anna L. Huguenard, Brandon A. Miller, and Joshua J. Chern


Intraventricular hemorrhage (IVH) is the most common cause of hydrocephalus in the pediatric population and is particularly common in preterm infants. The decision to place a ventriculoperitoneal shunt or ventricular access device is based on physical examination findings and radiographic imaging. The authors undertook this study to determine if head circumference (HC) measurements correlated with the Evans ratio (ER) and if changes in ventricular size could be detected by HC measurements.


All cranial ultrasound (CUS) reports at the authors' institution between 2008 and 2011 were queried for terms related to hydrocephalus and IVH, from which a patient cohort was determined. A review of radiology reports, HC measurements, operative interventions, and significant clinical events was performed for each patient in the study. Additional radiographic measurements, such as an ER, were calculated by the authors. Significance was set at a statistical threshold of p < 0.05 for this study.


One hundred forty-four patients were studied, of which 45 (31%) underwent CSF diversion. The mean gestational age and birth weight did not differ between patients who did and those who did not undergo CSF diversion. The CSF diversion procedures were reserved almost entirely for patients with IVH categorized as Grade III or IV. Both initial ER and HC were significantly larger for patients who underwent CSF diversion. The average ER and HC at presentation were 0.59 and 28.2 cm, respectively, for patients undergoing CSF diversion, and 0.34 and 25.2 cm for those who did not undergo CSF diversion. There was poor correlation between ER and HC measurements regardless of gestational age (r = 0.13). Additionally, increasing HC was not found to correlate with increasing ERs on consecutive CUSs (φ = −0.01, p = 0.90). Patients who underwent CSF diversion after being followed with multiple CUSs (10 of 45 patients) presented with smaller ERs and HC than those who underwent CSF diversion after a single CUS. Just prior to CSF diversion surgery, the patients who received multiple CUSs had ERs, but not HC measurements, that were similar to those in patients who underwent CSF diversion after a single CUS.


The HC measurement does not correlate with the ER or with changes in ER and therefore does not appear to be an adequate surrogate for serial CUSs. In patients who are followed for longer periods of time before CSF shunting procedures, the ER may play a larger role in the decision to proceed with surgery. Clinicians should be aware that the ER and HC are not surrogates for one another and may reflect different pathological processes. Future studies that take into account other physical examination findings and long-term clinical outcomes will aid in developing standardized protocols for evaluating preterm infants for ventriculoperitoneal shunt or ventricular access device placement.

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Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group

Clinical article

Shobhan Vachhrajani, Anish N. Sen, Krishna Satyan, Abhaya V. Kulkarni, Sherri B. Birchansky, and Andrew Jea

, and axis. 5 Hypermobility from ligamentous laxity, epiphyseal variation, unique vertebral architecture, and incomplete ossification of the pediatric cervical spine may further cloud the diagnosis of a pathological state after trauma. Adult criteria for instability following upper cervical spine trauma have been inappropriately extrapolated to that of the pediatric age group, possibly because of the familiarity with their radiographic measurement techniques. These measurements, although accurate in defining relationships between anatomical structures, do not take

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Evolution of the postoperative sagittal spinal profile in early-onset scoliosis: is there a difference between rib-based and spine-based growth-friendly instrumentation?

Zhonghui Chen, Song Li, Yong Qiu, Zezhang Zhu, Xi Chen, Liang Xu, and Xu Sun

before and after the index surgery and at the latest follow-up ( Table 2 ). Annual T1–S1 growth was 0.85 ± 0.17 cm/year for the VEPTR group and 0.97 ± 0.19 cm/year for the GRI group (p = 0.087) during the lengthening period. TABLE 2. Radiographic measurements for both groups through treatment Parameter VEPTR Group GRI Group p Value Major coronal Cobb angle (°)  Pre–index surgery 74 ± 17 72 ± 16 0.742  Post–index surgery 50 ± 13 46 ± 15 0.457  Latest FU 47 ± 15 44 ± 12 0.595 T1–S1 spinal height (cm)  Pre–index surgery 24.5 ± 6.4 24.7 ± 7.3 0.939  Post–index surgery 27

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Clinical outcomes of the traditional dual growing rod technique combined with apical pedicle screws in the treatment of early-onset scoliosis: preliminary results from a single center

Yang Yang, Zhe Su, Shengru Wang, You Du, Yiwei Zhao, Guanfeng Lin, Xiaohan Ye, Nan Wu, Qianyu Zhuang, and Terry Jianguo Zhang

. Radiographic measurements included the Cobb angle of the main curve, apical vertebral translation (AVT), apical vertebral rotation (AVR), T1–12 height, T1–S1 height, space available for the lung (SAL) (i.e., concave hemithorax height/convex hemithorax height ratio), 18 upper thoracic kyphosis (T2–5), thoracic kyphosis (TK, T5–12), thoracolumbar kyphosis (T10–L2), lumbar lordosis (L1–S1), proximal junctional angle, trunk shift, and sagittal vertical axis. Proximal junctional kyphosis (PJK) was defined as a proximal junctional angle ≥ 10° and ≥ 10° greater than the preindex

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Evaluation of lateral atlantodental interval asymmetry in the pediatric age group: normative values

Stephen K. Mendenhall, Andrew Huh, Janit Pandya, Vincent Alentado, Karl Balsara, Chang Ho, and Andrew Jea


The revelation of normative radiographic measurements for the developing pediatric spine is incomplete. The purpose of this analysis was to determine the normal range of asymmetry of the lateral atlantodental interval (LADI) and define age- and sex-related differences.


A total of 3072 children aged 0–18 years who underwent CT scanning of the cervical spine were identified at Riley Hospital for Children between 2005 and 2017. Patients were stratified by sex and age (in years) into 36 cohorts. Following this stratification, patients within each group were randomly selected for inclusion until 15 patients in each group had been measured (quota sampling). A total of 540 patients were included for study. Right and left linear measurements were performed in the CT axial plane at the C-1 midlateral mass level.


The overall mean difference between the right and left LADI was 0.09 ± 1.23 mm (range -6.05 to 4.87 mm). The magnitude of this asymmetry remained statistically insignificant across age groups (p = 0.278) and sex (p = 0.889). The intraclass correlation coefficient was 0.805 (95% CI 0.779–0.829).


Asymmetry of the LADI is not unusual in asymptomatic children. There is no appreciable difference in magnitude of this asymmetry across age ranges and sex. Measurement of LADI asymmetry shows “good” reliability and is easy to perform. Pediatric neurosurgeons, emergency department physicians, and radiologists should be aware of normative values of asymmetry when interpreting CT scans of the cervical spine. This may prevent unnecessary further workup with dynamic CT or MRI.

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The relationship between Chiari 1.5 malformation and sleep-related breathing disorders on polysomnography

Nicholas Sader, Walter Hader, Aaron Hockley, Valerie Kirk, Adetayo Adeleye, and Jay Riva-Cambrin

-disordered breathing symptoms  Snoring 7 (87.5%)  Gasping 4 (50%)  Witnessed apnea 7 (87.5%)  Mouth breathing 5 (62.5%) Unless otherwise indicated, values are expressed as the number of patients (%). * Based on 7 individual patients; i.e., 1 patient had 2 decompressions. Percentages for symptoms are based on 8 cases. Preoperative Radiographic Measurements Table 2 summarizes the radiographic measurements for the patient group before surgical decompression. The median tonsillar and obex descent values below the

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Assessment of craniocervical motion in Down syndrome: a pilot study of two measurement techniques

Jonathan E. Martin, Brandon G. Rocque, Andrew Jea, Richard C. E. Anderson, Joshua Pahys, and Douglas Brockmeyer

also recognized, 21 the definition of instability at this level is vague, 12 and substantiation of the risk due to hypermobility is lacking. Despite the absence of supportive data, several groups recommend fusion based on specific radiographic measurements. 2 , 13 , 19 Given the potential for catastrophic injury in DS patients, 13 the ability to identify presymptomatic patients at risk is desirable. Although static radiographs have been used by some providers 8 , 14 for this purpose, Pueschel and Scola 17 and Selby et al. 18 demonstrated variable measurements

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A 2D threshold of the condylar–C1 interval to maximize identification of patients at high risk for atlantooccipital dislocation using computed tomography

Vijay M. Ravindra, Jay Riva-Cambrin, Kevin P. Horn, Jason Ginos, Russell Brockmeyer, Jian Guan, John Rampton, and Douglas L. Brockmeyer

be used to develop a 2D CCI imaging threshold for improving the diagnostic accuracy of AOD. An improvement in diagnostic accuracy could prevent any missed diagnoses of AOD while possibly minimizing the unnecessary use of radiographic imaging in pediatric trauma patients. The primary objective of this study was to identify specific radiographic measurements that characterize children at high risk for the presence of AOD. The secondary objective was to establish normal, age-based radiographic parameters of the pediatric cervical spine. Methods A single

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Analysis and interrater reliability of pB-C2 using MRI and CT: data from the Park-Reeves Syringomyelia Research Consortium on behalf of the Pediatric Craniocervical Society

Todd C. Hankinson, Gerald F. Tuite, Dagmara I. Moscoso, Leslie C. Robinson, James C. Torner, David D. Limbrick Jr., Tae Sung Park, and Richard C. E. Anderson

with pB-C2 greater than 9 mm ranged from 6.7% to 26.7%. This variation is likely due to the fact that several patients (19.3%–25.8% on T1-weighted MRI) had measurements between 8 and 10 mm, where an extremely small measurement difference resulted in or not crossing the 9-mm threshold in a given case. Magnitude of pB-C2 Values Given the range of neuroimaging sequences and modalities that are available, any effort to determine the reliability of a radiographic measurement should attempt to account for inherent variation between modalities. In examining images obtained