C2/3 instability: unusual cause of cervical myelopathy in a child with Down syndrome

Bilateral sagittal split mandibular osteotomies for enhanced exposure of the anterior cervical spine in children: technical note

The bilateral sagittal split mandibular osteotomy (BSSMO), a common maxillofacial technique for expanding the oropharynx during treatment of micrognathia, is a rarely employed but useful adjunct to improve surgical access to the ventral cervical spine in children. Specifically, it provides enhanced exposure of the craniocervical junction in the context of midface hypoplasia, and of the subaxial cervical spine in children with severe kyphosis. The authors describe their technique for BSSMO and evaluate long-term outcomes in patients. The pediatric neurosurgical database at a single center was queried to identify children who underwent BSSMO as an adjunct to cervical spine surgery over a 22-year study period (1993-2015). The authors retrospectively reviewed clinical and radiographic data in all patients. The authors identified 5 children (mean age 5.3 ± 3.1 years, range 2.1-10.0 years) who underwent BSSMO during cervical spine surgery. The mean clinical follow-up was 3.0 ± 1.9 years. In 4 children, BSSMO was used to increase the size of the oropharynx and facilitate transoral resection of the odontoid and anterior decompression of the craniocervical junction. In 1 patient with subaxial kyphosis and chin-on-chest deformity, BSSMO was used to elevate the chin, improve anterior exposure of the subaxial cervical spine, and facilitate cervical corpectomy. Careful attention to neurovascular structures, including the inferior alveolar nerve, lingual nerve, and mental branch of the inferior alveolar artery, as well as minimizing tongue manipulation and compression, are critical to complication avoidance. The BSSMO is a rarely used but extremely versatile technique that significantly enhances anterior exposure of the craniocervical junction and subaxial cervical spine in children in whom adequate visualization of critical structures is not otherwise possible.