To assess skull bone thickness from birth to skeletal maturity at different sites to provide a reference for the correct selection of pin type and pin placement according to age.
270 children and adolescents (age: 0–17 years) with a normal CT scan obtained at Emergency Department for other medical reasons were included. Skull thickness was measured on the axial plane CT scans at eight different sites of the vault: midline anterior (A) and posterior (P), right and left lateral (L), antero-lateral (AL), postero-lateral (PL).
From birth to skeletal maturity, L thickness was increased significantly less (+ 58%) compared with AL (+ 205%), P (+ 233%), PL (+ 247%), and A (+ 269%) thickness (P < 0.01). At the end of growth, the thickest and thinnest points of the vault (absolute value) were found at the P and L measurement sites, respectively (P < 0.01). Children aged < 4 years exhibited the highest variability in AL and PL skull bone thickness, with thickness < 3 mm observed in 85% (64/75 patients) and 92% (69/75 patients) of cases, respectively.
We recommend that the tip of the pin should not exceed 2–3 mm in children aged < 4, and 4 mm in children aged 4–6 years, to decrease the risk of inner table perforation. After the age of 7 years and 13 years, standard-sized pin tips (5 and 6 mm, respectively) may be safely used. Children aged < 4 years show significant variability in skull thickness, and therefore a CT scan may be required for this particular age group.
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Perry J, Nickel VL (1959) Total cervical-spine fusion for neck paralysis. J Bone Joint Surg Am 41:37–60
Bono CM (2007) The halo fixator. J Am Acd Orthop Surg 15(12):728–737
Bogunovic L, Lenke LG, Bridwell KH, Luhmann SJ (2013) Pre-operative halo-gravity traction for severe pediatric spinal deformity: complications, radiographic correction and changes in pulmonary function. Spine Deform 1:33–39
Sponseller PD, Takenage RK, Newton P et al (2008) The use of traction in the treatment of severe spinal deformity. Spine 33:2305–2309
Botte MJ, Byrne TP, Abrams RA, Garfin SR (1996) Halo skeletal fixation: techniques of application and prevention of complications. J Am Acad Orthop Surg 4(1):44–53
Caird M, Hesinger RN, Weiss N, Farley FA (2006) Complications and problems in halo treatment of toddlers: limited ambulation is recommended. J Pediatr Orthop 26(6):750–752
Arkader A, Hosalkar HS, Drummond DS, Dormans JP (2007) Analysis of halo-orthoses application in children less than three years old. J Child Orthop 1(6):337–344
Hayes VM, Silber JS, Siddiqi FN, Kondrachov D, Lipetz JS, Lonner B (2005) Complications of halo fixation of the cervical spine. Am J Orthop 34(6):271–276
Dormans JP, Criscitiello AA, Drummond DS et al (1995) Complications in children managed with immobilization in a halo vest. J Bone Joint Surg Am 77:1370–1373
Garfin SR, Butt MJ, Waters RL, Nickel VL (1986) Complications in the use of the halo fixation device. J Bone Joint Surg Am 68:320–325
Saeed MU, Dacuycuy MA, Kennedy DJ (2007) Halo pin insertion-associated bran abscess: case report and review of literature. Spine 32(8):E271–274
Goodman ML, Nelson PB (1987) Brain abscess complicating the use of halo orthosis. Neurosurgery 20:27–30
Tindall GT, Flanagan JF, Nashold BS (1959) Brain abscess and osteomyelitis following skull traction. Arch Surg 79:638–641
Garfin SR, Botte MI, Centeno RS, Nickel VL (1985) Osteology of the skull as it affects halo pin placement. Spine 10:696–698
Gregory BA, Snow RD, Brogdon BG, Williams JP (1997) Value of bone window images in routine brain CT: EXAMINATION beyond trauma. Appl Radiol 26:26–42
Pillai P, Sammet S, Ammirati M (2008) Application accuracy of computed tomography-based, image-guided navigation of temporal bone. Neurosurgery 63:326–332
Moreira-Gonzalez A, Papai FE, Zins JE (2006) Calvarial thickness and its relation to cranial bone harvest. Plast Reconstr Surg 117:1964–1971
Adeloye A, Katten KR, Silverman FN (1976) Thickness of the normal skull in the American blacks and whites. Am J Phys Anthropol 43:23–30
Ross MD, Lee KA, Castle WM (1976) Skull thickness of Black and White races. S Afr Med J 50:635–638
Blyth BJ, Bazarian JJ (2010) Traumatic alterations in consciousness: traumatic brain injury. Emerg Med Clin North Am 28(3):571–594
Mubarak SJ, Camp JF, Vuletich W, Wenger D, Garfin SR (1989) Halo application in the infant. J Pediatr Orthop 9(5):612–614
Garfin SR, Roux R, Botte MJ, Centeno R, Woo SL (1986) Skull osteology as it affects halo pin placement in children. J Pediatr Orthop 6(4):434–436
Letts M, Kaylor D, Gouw G (1988) A biomechanical analysis of halo fixation in children. J Bone Joint Surg Br 70:277–279
Loder RT (1996) Skull thickness and halo-pin placement in children: the effects of race, gender, and laterality. J Pediatr Orthop 16(3):340–343
Haas LL (1952) Roentgenological skull measurements and their diagnostic application. AJR 67:197–209
Stone JL, Gulabani A, Gorelick G, Vennemreddy S, Vannemreddy P (2013) Frontolateral pins for halo ring placement: reassessment of a common neurosurgical procedure with CT scan measurements of skull bone thickness. J Neurosurg Spine 19:744–749
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Domenech-Fernandez, P., Yamane, J., Domenech, J. et al. Analysis of skull bone thickness during growth: an anatomical guide for safe pin placement in halo fixation. Eur Spine J 30, 410–415 (2021). https://doi.org/10.1007/s00586-020-06367-x
- Spine surgery
- Cranial thickness
- Bone growth
- Children spine
- Skull development