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Child's Nervous System

, Volume 35, Issue 1, pp 97–106 | Cite as

Instrumented arthrodesis for non-traumatic craniocervical instability in very young children

  • M. Burhan JanjuaEmail author
  • Steven W. Hwang
  • Amer F. Samdani
  • Joshua M. Pahys
  • Ali A. Baaj
  • Roger Härtl
  • Jeffrey P. Greenfield
Original Paper
  • 230 Downloads

Abstract

Purpose

Occipitocervical instrumentation is infrequently required for stabilization of the axial and subaxial cervical spine in very young children. However, when it is necessary, unique surgical considerations arise in children when compared with similar procedures in adults.

Methods

The authors reviewed literature describing fusion of the occipitocervical junction (OCJ) in toddlers and share their experience with eight cases of young children (age less than or equal to 4 years) receiving occiput to axial or subaxial spine instrumentation and fixation. Diagnoses and indications included severe or secondary Chiari malformation, skeletal dysplastic syndromes, Klippel-Feil syndrome, Pierre Robin syndrome, Gordon syndrome, hemivertebra and atlantal occipitalization, basilar impression, and iatrogenic causes.

Results

All patients underwent occipital bone to cervical spine instrumentation and fixation at different levels. Constructs extended from the occiput to C2 and T1 utilizing various permutations of titanium rods, autologous rib autografts, Mersilene sutures, and combinations of autografts with bone matrix materials. All patients were placed in rigid cervical bracing or halo fixation postoperatively. No postoperative neurological deficits or intraoperative vascular injuries occurred.

Conclusion

Instrumented arthrodesis can be a treatment option in very young children to address the non-traumatic craniocervical instability while reducing the need for prolonged external halo vest immobilization. Factors affecting fusion are addressed with respect to preoperative, intraoperative, and postoperative decision-making that may be unique to the toddler population.

Keywords

Occipital bone Cervical spine Occipitocervical instability Instrumentation Occipitocervical fusion 

Notes

Acknowledgements

All authors agreed to the final proof the paper.

Compliance with ethical standards

Conflict of interest

Janjua: Nothing to disclose.

Samdani: Consultant for DePuy Synthes Spine, Globus Medical, Ethicon, Misonix, Stryker, Zimmer Biomet.

Baaj: Royalties Thieme Medical Publishers, honoraria AO Spine.

Härtl: Consultant for DePuy Synthes Spine.

Pahys: Consultant for DePuy Synthes Spine, Globus Medical, Zimmer Biomet.

Hwang: Speakers bureau Zimmer Biomet.

Greenfield: Nothing to disclose.

References

  1. 1.
    Burgos-Vargas R, Clark P (1989) Axial involvement in the seronegative enthesopathy and arthropathy syndrome and its progression to ankylosing spondylitis. J Rheumatol 16:192–197Google Scholar
  2. 2.
    Dietrich AM, Ginn-Pease ME, Bartkowski HM, King DR (1991) Pediatric cervical spine fractures: predominantly subtle presentation. J Pediatr Surg 26:995–999 discussion 999-1000CrossRefGoogle Scholar
  3. 3.
    Foster HE, Cairns RA, Burnell RH, Malleson PN, Roberton DM, Tredwell SJ, Petty RE, Cabral DA (1995) Atlantoaxial subluxation in children with seronegative enthesopathy and arthropathy syndrome: 2 case reports and a review of the literature. J Rheumatol 22:548–551Google Scholar
  4. 4.
    Fox MW, Onofrio BM, Kilgore JE (1993) Neurological complications of ankylosing spondylitis. J Neurosurg 78:871–878.  https://doi.org/10.3171/jns.1993.78.6.0871 CrossRefGoogle Scholar
  5. 5.
    Gluf WM, Brockmeyer DL (2005) Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 67 pediatric patients. J Neurosurg Spine 2:164–169CrossRefGoogle Scholar
  6. 6.
    Hamilton MG, MacRae ME (1993) Atlantoaxial dislocation as the presenting symptom of ankylosing spondylitis. Spine (Phila Pa 1976) 18:2344–2346CrossRefGoogle Scholar
  7. 7.
    Lowry DW, Pollack IF, Clyde B, Albright AL, Adelson PD (1997) Upper cervical spine fusion in the pediatric population. J Neurosurg 87:671–676CrossRefGoogle Scholar
  8. 8.
    Platzer P, Jaindl M, Thalhammer G, Dittrich S, Kutscha-Lissberg F, Vecsei V, Gaebler C (2007) Cervical spine injuries in pediatric patients. J Trauma 62:389–396 discussion 394-386CrossRefGoogle Scholar
  9. 9.
    Tredwell SJ, Newman DE, Lockitch G (1990) Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 10:602–606CrossRefGoogle Scholar
  10. 10.
    Cirak B, Ziegfeld S, Knight VM, Chang D, Avellino AM, Paidas CN (2004) Spinal injuries in children. J Pediatr Surg 39:607–612CrossRefGoogle Scholar
  11. 11.
    Kokoska ER, Keller MS, Rallo MC, Weber TR (2001) Characteristics of pediatric cervical spine injuries. J Pediatr Surg 36:100–105CrossRefGoogle Scholar
  12. 12.
    Eleraky MA, Theodore N, Adams M, Rekate HL, Sonntag VK (2000) Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 92:12–17Google Scholar
  13. 13.
    Kennedy BC, D'Amico RS, Youngerman BE, McDowell MM, Hooten KG, Couture D, Jea A, Leonard J, Lew SM, Pincus DW, Rodriguez L, Tuite GF, Diluna ML, Brockmeyer DL, Anderson RC, Pediatric Craniocervical S (2016) Long-term growth and alignment after occipitocervical and atlantoaxial fusion with rigid internal fixation in young children. J Neurosurg Pediatr 17:94–102.  https://doi.org/10.3171/2015.5.PEDS14728 CrossRefGoogle Scholar
  14. 14.
    Hwang SW, Gressot LV, Rangel-Castilla L, Whitehead WE, Curry DJ, Bollo RJ, Luerssen TG, Jea A (2012) Outcomes of instrumented fusion in the pediatric cervical spine. J Neurosurg Spine 17:397–409.  https://doi.org/10.3171/2012.8.SPINE12770 CrossRefGoogle Scholar
  15. 15.
    Lauweryns P (2010) Role of conservative treatment of cervical spine injuries. Eur Spine J 19(Suppl 1):S23–S26.  https://doi.org/10.1007/s00586-009-1116-4 CrossRefGoogle Scholar
  16. 16.
    Brockmeyer DL, Brockmeyer MM, Bragg T (2011) Atlantal hemi-rings and craniocervical instability: identification, clinical characteristics, and management. J Neurosurg Pediatr 8:357–362.  https://doi.org/10.3171/2011.7.PEDS1138 CrossRefGoogle Scholar
  17. 17.
    Mazur MD, Sivakumar W, Riva-Cambrin J, Jones J, Brockmeyer DL (2014) Avoiding early complications and reoperation during occipitocervical fusion in pediatric patients. J Neurosurg Pediatr 14:465–475CrossRefGoogle Scholar
  18. 18.
    Ehara S, el-Khoury GY, Sato Y (1988) Cervical spine injury in children: radiologic manifestations. AJR Am J Roentgenol 151:1175–1178.  https://doi.org/10.2214/ajr.151.6.1175 CrossRefGoogle Scholar
  19. 19.
    Ha S, Lee SH, Kim ES, Shin HJ, Eoh W (2015) Highly unstable cervical spine injury in an infant: a case report. Childs Nerv Syst 31:341–346.  https://doi.org/10.1007/s00381-014-2527-z CrossRefGoogle Scholar
  20. 20.
    Hamoud K, Hershkovitz I, Hanani A, Marom L, Abbas J (2012) Internal stabilization of a flexion-distraction injury of the upper cervical spine of a toddler: a new technique and literature review. Spine (Phila Pa 1976) 37:E400–E407.  https://doi.org/10.1097/BRS.0b013e31822e82e5 CrossRefGoogle Scholar
  21. 21.
    Odent T, Bou Ghosn R, Dusabe JP, Zerah M, Glorion C (2015) Internal fixation with occipital hooks construct for occipito-cervical arthrodesis. Results in 14 young or small children. Eur Spine J 24:94–100.  https://doi.org/10.1007/s00586-014-3436-2 CrossRefGoogle Scholar
  22. 22.
    Benzel EC, Zhang DH, Iannotti C, Refai D, Ruggieri P, Krishnaney A (2012) Occipitocervical fusion in an infant with atlantooccipital dislocation. World Neurosurg 78(715):e717–e724.  https://doi.org/10.1016/j.wneu.2011.12.079 Google Scholar
  23. 23.
    Abumi K, Takada T, Shono Y, Kaneda K, Fujiya M (1999) Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems. Spine (Phila Pa 1976) 24:1425–1434CrossRefGoogle Scholar
  24. 24.
    Jeanneret B, Gebhard JS, Magerl F (1994) Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord 7:222–229CrossRefGoogle Scholar
  25. 25.
    Oda I, Abumi K, Sell LC, Haggerty CJ, Cunningham BW, McAfee PC (1999) Biomechanical evaluation of five different occipito-atlanto-axial fixation techniques. Spine (Phila Pa 1976) 24:2377–2382CrossRefGoogle Scholar
  26. 26.
    Evans DL, Bethem D (1989) Cervical spine injuries in children. J Pediatr Orthop 9:563–568CrossRefGoogle Scholar
  27. 27.
    Hooley E, Chaput CD, Rahm M (2006) Internal fixation without fusion of a flexion-distraction injury in the lower cervical spine of a three-year-old. Spine (Phila Pa 1976) J 6:50–54Google Scholar
  28. 28.
    Fagerstrom T, Hedlund R (2002) Cotrel Dubousset instrumentation in occipito-cervico-thoracic fusion. Eur Spine J 11:364–374.  https://doi.org/10.1007/s00586-002-0392-z CrossRefGoogle Scholar
  29. 29.
    Koop SE, Winter RB, Lonstein JE (1984) The surgical treatment of instability of the upper part of the cervical spine in children and adolescents. J Bone Joint Surg Am 66:403–411CrossRefGoogle Scholar
  30. 30.
    Flint GA, Hockley AD (1987) Internal fixation for atlanto-axial instability in children. Childs Nerv Syst 3:368–370CrossRefGoogle Scholar
  31. 31.
    Higo M, Sakou T, Taketomi E, Kojyo T (1995) Occipitocervical fusion by Luque loop rod instrumentation in Down syndrome. J Pediatr Orthop 15:539–542CrossRefGoogle Scholar
  32. 32.
    Helenius I, Crawford H, Sponseller PD, Odent T, Bernstein RM, Stans AA, Hedequist D, Phillips JH (2015) Rigid fixation improves outcomes of spinal fusion for C1-C2 instability in children with skeletal dysplasias. J Bone Joint Surg Am 97:232–240.  https://doi.org/10.2106/JBJS.N.00503 CrossRefGoogle Scholar
  33. 33.
    Mueller OM, Gasser T, Hellwig A, Dohna-Schwake C, Sure U (2010) Instable cervical spine injury in a toddler: technical note. Childs Nerv Syst 26:1625–1631.  https://doi.org/10.1007/s00381-010-1141-y CrossRefGoogle Scholar
  34. 34.
    Visocchi M, Della Pepa GM, Doglietto F, Esposito G, La Rocca G, Massimi L (2011) Video-assisted microsurgical transoral approach to the craniovertebral junction: personal experience in childhood. Childs Nerv Syst 27:825–831CrossRefGoogle Scholar
  35. 35.
    Visocchi M, Fernandez E, Ciampini A, Di Rocco C (2009) Reducible and irreducible os odontoideum in childhood treated with posterior wiring, instrumentation and fusion. Past or present? Acta Neurochir 151:1265–1274CrossRefGoogle Scholar
  36. 36.
    Visocchi M, Pietrini D, Tufo T, Fernandez E, Di Rocco C (2009) Pre-operative irreducible C1–C2 dislocations: intra-operative reduction and posterior fixation. The “always posterior strategy”. Acta Neurochir 151:551–559 discussion 560CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Neurological Surgery, New York Presbyterian HospitalWeill Cornell Medical CollegeNew YorkUSA
  2. 2.Shriners Hospitals for Children—PhiladelphiaPhiladelphiaUSA
  3. 3.Department of Orthopaedic and Neurological SurgeryUniversity of Pennsylvania HospitalPhiladelphiaUSA

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