Post-traumatic cervical kyphosis in children cannot be prevented by non-operative methods

Acute Progressive Pediatric Post-Traumatic Kyphotic Deformity

Cervical kyphosis is a rare entity with challenging management due to the limitations of pediatric age, along with a growing spine. The pathogenesis is made up of a large group of congenital, syndromic and acquired deformities after posterior element deterioration or as a result of previous trauma or surgery. In rare progressive cases, kyphotic deformities may result in severe "chin-on-chest" deformities with severe limitations. The pathogenesis of progression to severe kyphotic deformity after minor hyperflexion trauma is not clear without an obvious MR pathology; it is most likely multifactorial. The authors present the case of a six-month progression of a pediatric cervical kyphotic deformity caused by a cervical spine hyperflexion injury, and an MR evaluation without the pathology of disc or major ligaments. Surgical therapy with a posterior fixation and fusion, together with the preservation of the anterior growing zones of the cervical spine, are potentially beneficial strategies to achieve an excellent curve correction and an optimal long-term clinical outcome in this age group.

Development of New-Onset Cervical Deformity in Nonoperative Adult Spinal Deformity Patients With 2-Year Follow-Up

Purpose

Evaluate the presence of new-onset cervical deformity (CD) in nonoperative adult spinal deformity (ASD) patients with extended follow-up, with consideration for predictors, prevalence, and impact on patient-reported outcomes.

Methods

Retrospective review of a prospective nonoperative ASD cohort. New onset CD patients at 1- (CD-1Y) and 2-year (CD-2Y) follow-up were defined as displaying baseline cervical alignment. Univariate analyses determined differences in radiographic parameters and outcome scores of CD and maintained-cervical-alignment patients. Multivariate binary logistic regression models determined new-onset CD predictors.

Results

A total of 143 patients were included (mean age 54 years, mean body mass index 25.6 kg/m², 86% female). Cervical deformity rate was 38.5% at baseline. New-onset CD incidence at 1- and 2-year follow-up was 30.0% and 41.7%, respectively. Global sagittal profile comparison of CD-1Y/CD-2Y versus maintained cervical alignment cases revealed no differences (P > .05) at any interval. Baseline C2-C7 sagittal vertical axis (SVA) was associated with increased new-onset CD risk at 1 (odds ratio [OR] 1.14, P = .025) and 2 years (OR 1.04, P = .032); prior spine surgical history was associated with CD risk at 1-year follow-up (OR 6.75, P = .047); baseline C2 slope was associated with increased CD risk at 2-year follow-up (OR 1.12, P = .041). CD development did not significantly impact health-related quality of life (P > .05).

Conclusions

Cervical deformity can manifest in nonoperative ASD patients: 30.0% at 1-year follow-up, and 41.7% at 2-year follow-up. Progressive CD manifested independently of thoracolumbar profile changes. Increased baseline C2-C7 SVA, C2 slope, and prior surgical history increased new-onset CD odds at 1 and 2 years.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes

OBJECTIVE

To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion.

PATIENTS AND METHODS

Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication.

RESULTS

A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001).

CONCLUSION

Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.

A Radiographic Analysis of Cervical Sagittal Alignment in Adolescent Idiopathic Cervical Kyphosis

OBJECTIVE

The aim of this study was to analyze the radiologic features of adolescent idiopathic cervical kyphosis.

SUMMARY OF BACKGROUND DATA

There are few previous reports about radiographic analysis of cervical sagittal alignment of adolescent idiopathic cervical kyphosis. A new method was proposed in this article to evaluate the severity of cervical kyphosis.

PATIENTS AND METHODS

A total of 41 adolescent patients with cervical kyphosis were reviewed. Several angles were measured from the radiographs utilizing the 2-line Cobb method and Harrison posterior tangent method. Ishihara's Curvature Index (CI), Kyphosis Index (KI), kyphosis levels, and the apex of the kyphosis were also measured.

RESULTS

The results showed that the apex of the kyphosis is located at the posterior-superior edge of C4 (70.7%) and C5 (29.3%). C2-C7 angles ranged from 4.7 to 71.3 degrees (36.2±13.6 degrees) and from 9.8 to 83.1 degrees (36.4±15.1 degrees) in the above 2 methods, respectively. Local angles of kyphotic area ranged from 21.8 to 96.3 degrees (50.5±23.7 degrees) in 2-line Cobb method and from 19.8 to 105.6 degrees (52.0±19.5 degrees) in Harrison posterior tangent method. CI and KI ranged from 8.6 to 79.8 (36.8±16.7) and 15.2 to 141.9 (50.6±23.7), respectively. Statistical analysis showed that there was significant positive correlation between KI and kyphosis angle.

CONCLUSIONS

In adolescent idiopathic cervical kyphosis, the alteration of the sagittal profile only occurs on partial cervical alignment rather than the whole cervical spine. The apex of the kyphosis locates at posterior-superior edge of the vertebrae. It seems that KI can accurately depict the severity of cervical kyphosis.

Unstable Cervical Spinal Injury in Children - Case Report and Review of the Literature

Large studies about the management of pediatric patients with unstable flexion-distraction injuries of the midcervical spine are rare. We present the case of a 12-year-old girl who sustained a cervical spinal injury with unilateral facet dislocation and discuss details and problems of diagnostic procedures and treatment in the light of the recent literature. The management and pitfalls of a unilateral facet dislocation in a child are summarized. After initial reposition, a multisegmental instability with neurology developed. Although distraction-flexion cervical spine injuries are common in adults and often occur with concomitant neurological sequelae, they also can occur in the pediatric population. In conclusion, an MRI seems advisable. A treatment of postoperative malalignment with reposition via a halo-fixator cannot be recommended. Repositioning is possible but was lost when the fixator was removed. Comparing the historic and recent literature there is only weak evidence overall, nevertheless a ventral fusion seems to be the treatment option of choice.

Cervical spine trauma in children: a review

Injuries of the cervical spine are relatively rare in children but are a distinct clinical entity compared with those found in adults. The unique biomechanics of the pediatric cervical spine lead to a different distribution of injuries and distinct radiographic features. Children younger than 9 years of age usually have upper cervical injuries, whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower cervical injuries. Pediatric cervical injuries are more frequently ligamentous in nature, and children are also more prone to spinal cord injury without radiographic abnormality than adults are. Physical injuries are specific only to children. Radiographically benign findings, such as pseudosubluxation and synchondrosis, can be mistaken for traumatic injuries. External immobilization with a halo brace can be difficult and is associated with a high complication rate because of the thin calvaria in children. Surgical options have improved with the development of instrumentation specifically for children, but special considerations exist, such as the small size and growth potential of the pediatric spine.

Temporary anterior cervical plating in a child with traumatic cervical ligamentous instability

Application of anterior cervical plates in children is problematic because of the growing spine, and thus has been reported only rarely in the medical literature. In this case report, a 7-year-old with traumatic C(2-3) and C(3-4) ligamentous instability was treated surgically by limited-duration anterior cervical plating. The plate was removed in a second operation, as the osseous union occurred 1 year after the primary operation. Limited-duration anterior cervical plating is an alternative for stabilization operations of the growing cervical spine in children.

Management of pediatric cervical spine and spinal cord injuries

DIAGNOSTIC

STANDARDS

There is insufficient evidence to support diagnostic standards.

GUIDELINES

In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained.

OPTIONS

In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis.

TREATMENT

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.

Traumatic subluxation of the axis after hyperflexion injury of the cervical spine in children

Six cases of children (four boys and two girls, mean age 11 years) who had traumatic subluxation of the axis (C2) were reviewed retrospectively. Initial radiographs demonstrated no detectable vertebral fracture in any of the children. However, a slight anterior subluxation of C2 was observed in three of the patients. Radiographs, taken at 1 month after injury in all but one patient, revealed a progression of the subluxation and a local kyphosis in all of the patients. Four of the children were treated conservatively with a cervical brace, and an improvement of both the kyphosis and the anterior slippage of C2 was obtained accompanied by an anteroposterior growth of the C3 vertebral body. The kyphosis of two of the patients became severe and, ultimately, these patients underwent fusion surgery. At the follow-up, none of the patients presented with any significant symptom. For the correct diagnosis of traumatic subluxation of C2, sequential radiographs to confirm the progression of subluxation and local kyphosis are mandatory. Conservative treatment rather than early surgical treatment may be chosen for this injury, because mild and moderate kyphosis can be corrected spontaneously by remodeling of the cervical spine.