Growing Spine


Fig. 1

(a) Thoracic vertebra. Transverse section. Fourth month of intrauterine life. The ossification centers are now in place in the future vertebral body and in the posterior arcs. (b) Three successive and overlapping phases: Mesenchyme, Cartilage, and Ossification. According to Tsou. Embryology of congenital kyphosis. Clin Orthop 1977, 128, 18–25 (with his permission)


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Fig. 2

Ossification of the spine in the third month of intrauterine life


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Fig. 3

The morphology of the vertebral body evolves: (a) at 3 months of intrauterine life, (b) at 4 months of intrauterine life, and (c) at 8 years. The osseous nucleus changes its morphology, it has the shape of a lens at 3 months, then it is ovoid at 4 months of intrauterine life, and quadrangular at 8 years


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Fig. 4

Cellular organization of the vertebral body around the vessels: (a) 2 months of intrauterine life and (b) 4 months of intrauterine life. The upper and lower parts of the vertebral body are marked by growth cartilage (Baldet)



The growth cartilage roles are well distributed; the programming is hierarchical.


Without going back to the main embryonic stages, we note (Fig. 5) the following:



  • the decisive role of the future notochord



  • the redistribution of sclerotomes… crucial time



  • the closing of the posterior arc which is linked to the closure of the tube.


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Fig. 5

Cartilage growth. Histological structure: with its germ cells, its column cells, its chondrocytes, and its ossification front


The sequences are linked to an immutable rhythm.


The failed closure of the neural stem (which normally closes around the 4th week of intrauterine life) determines the persistent opening of the posterior arch. All of these multiple, complex processes are contemporary and can be associated. This explains why a vertebral malformation can be a polymalformation (eg, spina bifida).


The vertebral body is a vascular sponge.


The Fetal Period: The Strongest of All Growth Is the Intra-Uterine Period


The fetal period extends from Day 60 to birth. It corresponds to the very beginning of the ossification of the vertebral body. Cartilage is gradually replaced by the mesenchyme (Figs. 6 and 7).

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Fig. 6

The vertex–coccyx distance . In the fetus, at 3 months, it is about 10 cm and reaches 25 cm at 4 months. Thus, between the 3rd and the 4th month, growth is very important. In the 5th month, the vertex–coccyx distance is 30 cm, and will be 34 to 35 cm at birth


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Fig. 7

Sagittal section of the spine at 8 months. Ossification is first posterior; it extends radiating upwards and downwards


The appearance of cartilage is rapidly followed by ossification fronts that progress in the posterior arcs as well as the center of the vertebra.


During the fetal period, the proportions change. In the 2nd month of intrauterine life, the spine is about 2/3 of the length of the body. This proportion gradually changes as the lower extremities develop (Fig. 8).

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Fig. 8

The morphology of the vertebral body evolves. The marginal listel appears at the beginning of puberty; the complete integration of all the listels can occur until the age of 25 years


In the 5th month of intrauterine life , the length of the spine represents only 3/5 of the total length of the fetus. It represents only 2/5 at birth toward adulthood (Fig. 9).

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Fig. 9

Neurocentral cartilage has bidirectional activity. It contributes posteriorly to the ossification of the posterior arc and anteriorly to a third of the ossification of the vertebral body


Annual growth rate vertex–coccyx: 44 cm!


The vertex–coccyx distance.


The neurocentral cartilage has a bidirectional activity.


Vertebral ossification does not occur simultaneously or in parallel across the bony parts of the vertebral column. It begins in the cervical region and then progresses smoothly up and down to the coccyx, at the level of the vertebral body. It first appears in the thoracic region, and then from this thoracic region, it progresses to the lumbar region and to the cervical region. The ossification nucleus of the vertebral body morphology changes. It is at first ovoid and becomes rectangular with time (Fig. 10).

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Fig. 10

Congenital scoliosis . The slightest aggression during embryonic life may be responsible for a malformation of the spine. The hemivertebra deforms the growing spine in the frontal and sagittal plane


The ossification of the odontoid and the apex of the odontoid is very late, as are those of the sacral pieces (Fig. 11).

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Fig. 11

Congenital kyphosis by failure of segmentation


The work of ossification progresses extremely slowly. It begins in the 2nd month of intrauterine life but only ends around the 18th year, and for some, at the 25th year!


Vertebral Curves Are Not Primitive But Acquired


During the first period of intrauterine life, the vertebral column is substantially rectilinear or with a slight anterior concave curve (Figs. 12 and 13). In the 5th month occurs a slight sacro-vertebral angle, establishing the respective limit of the lumbar region and the sacral region. But even at birth, there is virtually no trace of the inflections that characterize the cervical or lumbar regions.

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Fig. 12

Evolution of spinal curvatures. Fetus at 3 months: large “C” curvature. Fetus at 4 months: note the appearance of the sacro-vertebral angle. From birth to 1 year: spinal curvatures depending on the neurological calendar. The holding of the head heralds the cervical lordosis, the holding of the trunk, the thoracic kyphosis and the postural verticalization is accompanied by the lumbar curvature


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Fig. 13

Growth is a change of proportions. The lower limbs grow larger than the trunk, the cephalic sphere diminishes in proportion. At birth, the lower limbs measure 15 cm; sitting height 35 cm; at the end of growth, the sitting height represents 52–53% of the standing height


In the fetus the vertex–coccyx distance is 10 cm at 3 months and 25 cm at 4 months— the growth is very important between the 3rd and 4th months. At the 5th month, the vertex–coccyx distance is 30 cm and it will be 35 cm at birth (Fig. 6).


At Birth, 30% of the Spine Is Ossified


At birth, two elements will play a key role (Fig. 13):



  • neurological maturation



  • sitting height whose evolution directly reflects vertebral growth.


At birth, the vertebrae have three centers of ossification: one for the central anterior part, one for each posterior arc. The length at the end of growth will have almost tripled.


About 30% of the spine is ossified at birth. There is no significant difference between the vertebrae. The vertebral body of a thoracic vertebra is about 7 mm in height. The sitting size measures 35 cm.


Evolution of spinal curvatures


Growth is a change of proportions


The First Five Years of Life Are Decisive: Living Growth


The first year of life is dominated by two events (Figs. 14, 15, 16, and 17):



  • the establishment of the osseous medulla, which is adjusted relative to its container (cortex);



  • the constitution of cervical, thoracic, and lumbar curvatures which are dependent on verticalization.


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Fig. 14

Annual speed of male sitting height—12.4 cm gain in the first year of life; note the slowdown after the age of 5. From 0 to 5 years, sitting height increases as much as the lower limb. After 5 years and until puberty, the lower limb increases more than the trunk. After puberty, the trunk grows larger than the lower limb


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Fig. 15

Annual growth rate of sitting waist in the girl. The sitting height gain is 12 cm in the first year of life; after the age of 5 and until puberty: annual gain is about 2.4 cm


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Fig. 16

Average sitting height in the boy. At the end of growth, the average sitting height of a boy measuring 1.75 m is 92 cm


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Fig. 17

Average sitting height in the girl. At the end of growth, the average sitting height of a girl who measures 1.67 m is 88 cm


Once erect, around the age of 1 year, the cervical curvature and lumbar curvature settle, they are dependent on neuromotor development and neurological maturation which is cephalocaudal.


After 5 years, the lower limbs grow 3.5 cm per year.


During the first year of life, the vertebral body may present as two ossification nuclei, but these small occurrences in ossification will unify rapidly. On the other hand, the coronal cleft, which is visible sometimes at birth, will disappear during the first year. This radiographic image can be visualized until the age of 4, and it must be considered as a variation of endochondral ossification.


From 1 to 5 years, the medullary systemization is refined.


Once the closure of neurocentral synchondrosis is completed, then commences the closure of the posterior arc, then only one can really speak of the posterior arc and vertebral body, whereas the denomination which precedes these actions is the following one: neural arc for the posterior part and central point for the future vertebral body.


Growth during this period remains very strong. The sitting height gain is 12 cm in the first year of life; the sitting height then increases from 35 to 47 cm. From 1 to 5 years the sitting height gain is 15 cm; sitting height increases from 47 to 62 cm.


The sitting height at the end of growth represents 52% of the standing height.


Sitting height has increased by 27 cm in 5 years! The remaining growth of sitting height after 5 years is 30 cm. In other words, within a few centimeters the spine grows as much during the first 5 years of life as during all of the rest of growth. It is necessary to put in perspective this increase of growth of the first 5 years of the life (+27 cm) compared to the puberty period where the sitting height grows 12–14 cm.


This growth spurt in the first 5 years of life is even stronger than during the pubertal period.


Growth Between 5 Years and the Beginning of the Puberty


From 5 to 10 years, the growth of the trunk, and therefore of the spine, slows down as the sitting height will increase by about 10 cm. The annual growth rate of the trunk is 2 cm. The T1-LS segment grows 1.2 cm per year. The annual elongation of the T1-L5 spine should theoretically not exceed 1.2 cm per year. We must exploit this soft growth, especially when we manage an infantile scoliosis.


Puberty, a Decisive Turn: New Acceleration


The pubertal peak begins at 11 years of bone age in the girl. The remaining growth in sitting height is about 12 cm, including 2 years of strong growth where the sitting height will increase by 7 cm and 3 years of soft growth where the sitting height will increase by only 5 cm. Growth slows down after the closing of the elbow growth cartilages.


The pubertal peak in the boy starts later, at 13 years of bone age. The remaining growth on the sitting size is 13 cm: a sharp growth for 2 years, 13–15 years of bone age, with a sitting height gain of 8 cm and a gentle growth at 15–18 years, where the sitting height gain is 5 cm.


Growth slows down significantly after the closure of the elbow growth cartilages.


All these figures are valuable because sitting height is a reflection of macrocrine growth, and this macrocrine growth is the product of microcurrents that occur mainly in the spine.


Between the ages of 10 and 17, the vertebra has almost doubled in size. It is at the time of puberty that the secondary ossification nuclei appear (especially at the level of the posterior arc) and the marginal vertebral apophysis that comes to sit above and below the vertebral body (Fig. 8).


Each Level of the Spine: A Different Growth


The spine has almost tripled in length from birth to adulthood. It measures in adulthood of 70 cm in the boy, 65 cm in the girl. The cervical spine measures approximately 12 cm; thoracic spine of about 28 cm; the lumbar spine of approximately 18 cm; the sacrum of approximately 12 cm. The medullary canal reaches at 5 years 95% of its final size (Figs. 18 and 19).

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Fig. 18

From left to right. Cervical spine 2nd vertebra at birth, 5 years old, 10 years old, adulthood. From the age of 5, the cervical spine is fully grown. Inferior cervical spine, C4 at birth, 5 years old, 10 years old, and as an adult


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Fig. 19

Central spinal canal at the end of growth. (a) The cervical vertebra admits the thumb. (b) The lumbar vertebra admits the index. (c) The thoracic vertebra admits the 5th finger


The Cervical Spine


The cervical spine represents 22% of C1-S1 segments. The volume of the cervical spine is 9 cm3 at birth. It is 110 cm3 at the end of growth. It has been multiplied by 12.


It measures 3.7 cm at birth and 12–13 cm at the end of growth. It has almost quadrupled in length. It represents approximately 15% of the sitting height at the end of growth and as mentioned, 22% of the C1S1 segment. The cervical cord is comfortable in the medullary canal. It occupies in the adult a surface of 80 mm2, while the average surface of the vertebral canal is of the order of 376 mm2.


It is necessary to differentiate the high cervical spine C1-C2 and the low cervical spine.


Central Spinal Canal at the End of Growth


Two entities must be distinguished:



  • the superior cervical spine: C1–C2.



  • the inferior (subaxial) cervical spine: C3–C4–C5–C6–C7.


Cervical Spine Height
























Dimensions


Newborn


6 years


10 years


15 years


3.7 cm


7.5 cm


10 cm


13 cm


From the age of 5 years the medullary canal reaches 95% of its area.


The Superior Cervical Spine


Characterized by its embryological singularity. The lower part of the 4th occipital sclerotome and the upper part of the 1st cervical sclerotome form the top of the odontoid (Figs. 20, 21, 22, 23, and 24). The lower part of the first cervical sclerotome and the upper part of the 2nd sclerotome form the atlas and the base of the odontoid (Fig. 25).

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Fig. 20

Evolution of the 4 occipital somites and the first 3 cervical somites . The darker areas represent the 2nd to the 4th occipital somites, which contribute to the formation of the superior cervical spine


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Fig. 21

Embryology: formation of the odontoid within the mesenchymal tissue


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Fig. 22

The growth cartilages of the first cervical vertebra. The 2 lateral nuclei of the body of the odontoid merge before birth


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Fig. 23

Odontoid in the 8th month of intrauterine life. The 2 body cores of the odontoid are about to merge


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Fig. 24

Odontoid at birth. Frontal cut


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Fig. 25

Cervical spine, sagittal cut. Ossification is initially dorsal and extends radiating upwards and downwards. Note that the odontoid process is still completely cartilaginous on an 8-month-old fetus


The lower part of the 2nd sclerotome and the upper part of the 3rd sclerotome form the body of the atlas (Fig. 26).

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Fig. 26

Cervical vertebra at birth. X-ray horizontal section. Note the importance of the cartilaginous mass; the vertebral body can appear only at the age of 1 year. The neurocentral cartilage merges. The 2 posterior arcs merge posteriorly toward 6 years


The Growth of the Atlas (Figs. 27, 28, and 29)


The body of the odontoid practically represents the body of the atlas, but they merge and fit into the vertebral body of the axis.

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Fig. 27

Odontoid calendar. Development of the second cervical vertebra. Two centers of ossification appear “in the heart of the odontoid” at the 4th month of the fetal life; they merge before birth. The fusion between the body of the odontoid and the neurocentral cartilages occurs around the age of 6 years. A nucleus of higher polar ossification appears around the age of 3. The odontoid bone fuses at the top of the odontoid with the body of the odontoid around the age of 12 years. The two neural arches fuse posteriorly around the age of 4, it persists at about 6 years, a much reduced growth sequence between the body of the odontoid and the body of the atlas


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Fig. 28

The odontoid process at age 8 is completely ossified


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Fig. 29

Morphological abnormalities of the odontoid. 1. Normal odontoid apophysis; 2. Atrophic odontoid apophysis; 3. Os odontoideum; 4. More severe os odontoideum malformation; 5. Absence of odontoid process


The atlas has two lateral ossification nuclei that become the lateral masses.


After the age of 8, there is no visible growth cartilage.


There is a third nucleus of ossification which is anterior and which also contributes to the formation of the posterior arc. This ossification nucleus does not appear sometimes before the age of 1 year. It can be bifid but it is not pathological.


The ossification of the atlas may be incomplete resulting from a pseudo spina bifida. It should not be confused with a fracture.


The Growth of the Axis Is Even More Complex


Ossification of the odontoid appears very early in the 5th month of intrauterine life. Two ossification centers appear and merge at birth. The top of the odontoid ossifies around the age of 6 years.


This terminal ossification fuses with the rest of the body of the odontoid at the age of 12 years.


The non-fusion of this center of ossification with the body of the odontoid creates the conditions of the odontoid bone whose pathogenesis is not very precise. Perhaps congenital? Traumatic?


The body of the odontoid is separated from the body of the axis by a growth cartilage. But this growth cartilage does not have a very elaborate structure. The body of the odontoid fuses with the body of the axis around the age of 6. In children, before the age of 6, an injury of the odontoid can therefore lead to detachment of this growth cartilage.


The Lower Cervical Spine


Apr 25, 2020 | Posted by in ORTHOPEDIC | Comments Off on Growing Spine
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