Pediatric Cervical Lordosis: Values, Disorders, and Interventions

Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines

Editor—AJCC

INTRODUCTION

The adult cervical lordosis has received considerable attention in the spine literature; where both average and idealized values and geometric shape of the cervical lordosis have been reported. The average adult cervical lordosis was 34° ± 9°between C2-C7 posterior vertebral body lines. In a follow-up paper in 2004, Harrison and colleagues² modeled the adult cervical lordosis (using a curve fitting method known as the least squares error) as a piece of a circle from C2-T1. Furthermore, they demonstrated statistically significant differences in adult cervical lordosis between normal subjects, acute neck pain subjects and chronic neck pain subjects.

Problematically, adult data for the cervical lordosis may not readily apply to children between the ages of birth to early adolescents and many clinicians may be incorrectly applying adult data to pediatric patients and outcomes.

Pediatric Normative Data

In many anatomy texts, it is often claimed and/or assumed that the cervical lordosis is a secondary curve and is not present during intra-uterine life. However, as early as 1977, Bagnall et al³ demonstrated that the cervical lordotic curve is formed in intrauterine life (9.5 weeks). In 195 fetuses, Bagnall et al³ found that by 9.5 weeks, 83% of fetuses have a cervical lordosis, 11% have a military configuration, and only 6% of fetuses are in the typically described kyphotic position of the cervical spine. This means that by 9.5 weeks, 94% of the fetuses are starting to use their posterior cervical muscles to pull the cervical curve away from the fetal “C”-shape. Fetuses have a cervical lordosis before birth, however, the lordosis increases during post-natal life at ages 3 months-9 months as the infant raises his/her head and begins to sit up.⁴

There is adequate information to suggest that the cervical lordosis increases from birth until about 2 years of age^3-6 and then decreases up until the age of 9 or 10, after which time the cervical curve increases until reaching early adulthood.⁵

In 1996, Kasai et al⁵ presented information on the development of the cervical lordosis in 360 Japanese children (180 boys and 180 girls) equally distributed in the age groups 2-18 years old. Subjects did not have neurological deficits or fractures, but were examined due to mild injury and symptoms in the neck. Radiographs were taken in the seated position and analyzed using the 4-line Cobb angle from C3-C7. It might be that sitting cervical lordosis is reduced compared to standing lordosis. Cervical lordosis was found to steadily decrease from the age of 2 years up to 9 years and then increase from 9 years up to 18 years of age. No differences were found between the sexes. Table I presents the means and Standard Deviations for cervical lordosis in each of the age ranges from this study.^5-6

Table 1.

Cervical lordosis values in Pediatrics and Adolescents between the ages of 2-17 years of age. There are 20 subjects in each age group and the posterior tangent method from C2-C7 is reported using data from Kasai et al⁵ and Harrison et al⁶ (Chapter 3).

2 yrs old	32.1°†
3 yrs old	30.6°†
20/4 yrs old	30.4°†
20/5 yrs old	27.8°†
20/6 yrs old	26.6°†
20/7 yrs old	23.4°†
20/8 yrs old	22.5°†
20/9 yrs old	21.5°†
20/10 yrs old	22.7°†
20/11 yrs old	23.8°†
20/12 yrs old	24.4°†
20/13 yrs old	25.3°†
20/14 yrs old	26.5°†
20/15 yrs old	25.8°†
20/16 yrs old	26.4°†
20/17 yrs old	27.5°†
20/18 yrs old	28.0°†

Abnormal Lordosis and Pediatric Health

Car accidents, falls, and poor posture might all contribute to abnormal cervical lordosis in pediatric populations. Ultimately, abnormal cervical lordosis may lead to a number of health-related disorders in children or childhood. For instance, in infants, the cervical lordosis has been found a necessity for proper respiration and opening of the velo-epiglotic and velo-glossal sphincters.⁷ According to Shatz et al,

“The most important anatomical parameter found to facilitate the switch from nasal to oral ventilation in human infants is a cervical extension, creating a physiological lordosis of the neck that results in an opening of the veloglossal and veloepiglottic sphincters.”⁷

In children aged nine years and up, McAviney et al⁸ found that reduced cervical lordosis was correlated to the presence of sub-acute and chronic cervico-genic pain. Also, evidence in the Chiropractic literature, suggests that correction of abnormal cervical lordosis in children may improve disorders such as ADHD, Asthma, Ear Infection, Headaches, and Neck Pain.^9-11

Conservative Interventions for Pediatric Patients

            Conservative interventions for rehabilitation of the abnormal pediatric cervical lordosis are multi-modal and can include adjustments, exercises, and spinal remodeling (traction) techniques. In CBP Technique, these procedures are performed using mirror image® methods. Figure 1 depicts a CBP Technique mirror image adjustment and Denneroll spinal remodeling orthotic device.

·      Pediatric Spinal Remodeling-Traction

Problematically, adult equipment for rehabilitation of the cervical lordosis on the market today is not specifically designed for the pediatric patient’s body size. Adult equipment applies considerable forces-loads to the spine and these loads may not be appropriate for pediatric spines. Lastly, adult devices can be cumbersome to use in children and they will not sit still in these devices; thus their bodies do not remain in neutral postures when in traction.

            For the above reasons, the pediatric Denneroll orthotic device was developed for pediatric specific use. (Figure 1). In Figure 2, a pediatric male’s x-ray is shown with a mid-cervical curve reversal. The child presented to my clinic with chronic cervico-genic pain that was unresponsive to previous chiropractic care at a separate facility. After 6 weeks (3-4 x per week) of intervention using the methods in Figure 1, a revaluation was performed. Follow up radiographs were obtained a minimum of 2-days since his last treatment and complete correction of the cervical lordosis has been achieved; the patient was now asymptomatic (Figure 2).

SUMMARY

            Pediatric cervical lordosis values can vary from that of the adult due to developmental changes in the spine and changing distribution of body masses. Preliminary evidence exists providing both normative data for cervical lordosis across ages and a relationship between abnormal cervical lordosis and pediatric health disorders. Adult ‘spinal remodeling’ devices may not be appropriate in size or forces for many children. It is for this reason that the pediatric Denneroll device was developed.

Though the evidence is preliminary, I would encourage Chiropractors interested in structural rehabilitation of the pediatric spine to utilize this device in selected cases as it appears to be reasonably effective for its purpose.

REFERENCES

1. Harrison DD, et al. Spine 1996; 21: 667-675.
2. Harrison DD, et al. Spine 2004; 29:2485-2492.
3. Bagnall KM, et al. J Anat 1977;124:791-802.
4. Kure S. J Tokyo Med Collage 1972;30;453-470.
5. Kasai T, et al. Growth. Spine 1996;21:2067-2073.
6. Harrison DE, Harrson DD, Haas JW. Evanston, WY: Harrison CBP Seminars, Inc., 2002, ISBN 0-9721314-0-X.
7. Shatz A, et al. Acta Anat 1994;149:141-145.
8. McAviney J, et al. J Manipulative Physiol Ther 2005;28:187-193.
9. Bastecki A, et al. ADHD: A CBP Case Study. J Manipulative Physiol Ther 2004; 27(8):e14.

10.   Fedrochuk C, Wheeler G. J Ped Maternal & Family Health-Chiropractic. 2009;4:1-7.

11.   Fedrochuk C, et al. J. Pediatric, Maternal & Family Health - June 17, 2009:1-8.

cervical lordosis, Chiropractic BioPhysics, pediatric normal lordosis values