The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment

Scott L. Zuckerman, Zeeshan M. Sardar, Christopher S. Lai, Gerard F. Marciano, Mena G. Kerolus, Ian A. Buchanan, Alex S. Ha, Meghan Cerpa, Michael P. Kelly, Stéphane Bourret, Kazuhiro Hasegawa, Hee Kit Wong, Gabriel Liu, Hwee Weng Dennis Hey, Hend Riahi, Jean Charles Le Huec, Lawrence G. Lenke

Research output: Contribution to journalArticlepeer-review

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Purpose: In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. Methods: A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18–80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student’s t tests, Kruskal–Wallis, Wilcoxon rank-sum, linear regression, and Pearson’s correlation were used with significance at p < 0.05. Results: 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005). Conclusion: Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.

Original languageEnglish (US)
Pages (from-to)3639-3646
Number of pages8
JournalEuropean Spine Journal
Issue number12
StatePublished - Dec 2021
Externally publishedYes


  • Asymptomatic cohort
  • Multi-ethnic alignment normative study (MEANS)
  • Normative spinal alignment
  • Odontoid-central sacral vertical line

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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