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Singh DK, Kumar R, Pathak V, Kaif M, Yadav K. C1-C2 coronal and sagittal joint angle based treatment algorithm for the need of transoral odointectomy in complex craniovertebral junction anomalies with Clinico-Radiological outcome analysis. Br J Neurosurg 2023; 37:1594-1603. [PMID: 36073850 DOI: 10.1080/02688697.2022.2118232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/23/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Craniovertebral junction (CVJ) pathology by virtue of its complexity is a surgical challenge in the realm of neurosurgery. We analyzed the need for transoral odointectomy in view of their C1-C2 joint coronal and sagittal angle of 58 patients with complex CVJ anomalies treated surgically. The clinical and radiological outcome of the patients was assessed and a treatment algorithm is proposed. METHODS A total of 58 cases were included in the Prospective study over the period of 2 years. Patients were evaluated clinically, investigated, and operated with reduction and rigid internal fixation with screws and rod. The clinical outcome was measured by Modified Japanese orthopedic association score(mJOA) and radiologically by conventional craniometrics indices. Paired 't' test used for statistical analysis. RESULTS Mean age of patients: 30 years, with mean, follow up: 20.5 months. 46(80%) patients were operated by posterior and 12(20%) by combined approach (anterior transoral with posterior). Occipitocervial fixation was done in 15(25.8%) cases and C1-C2 fixation in 43(74.2%) cases. As compared to patients with low coronal angle, the patient with coronal angle >65° needed anterior decompression (87.5%) and all (100%) had Occipitocervical fixation. Clinical outcome analysis showed significant improvement in mean mJOA score (preop 11.9 Vs postop 14.6) after surgery. All craniometrics indices were significantly improved after surgery. The overall complication rate was 10% with a mortality of 1.7%. 6 months follow up completed in all patients with a 100% fusion rate. CONCLUSION Occipitocervical fixation and anterior decompression is required in increased C1-C2 joint CA (>65°) for bony realignment and adequate decompression. Measurement of C1-C2 joint coronal and sagittal angle in complex CVJ anomalies will easily anticipate the surgeon regarding the need for anterior decompression inform of transoral odointectomy.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rakesh Kumar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Vipul Pathak
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Mohd Kaif
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Kuldeep Yadav
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
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Finkel RA, Narendran N, Nilssen PK, Skaggs DL, Illingworth KD. Vertebral Artery Dissection in the Setting of Unstable Os Odontoideum: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00054. [PMID: 38134303 DOI: 10.2106/jbjs.cc.23.00466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
CASE A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae. CONCLUSION This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum.
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Affiliation(s)
- Ryan A Finkel
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Tomita T. The evolution of pediatric neurosurgery: reflection of personal experience of the last half-century. Childs Nerv Syst 2023; 39:2571-2582. [PMID: 37486438 DOI: 10.1007/s00381-023-06068-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES In the past 50 years, pediatric neurosurgery has made tremendous strides, and gained its own identity as a distinct subspecialty. I have personally observed this progress and evolution in pediatric neurosurgery in multiple dimensions, which are described based upon my own experience and reflection. METHODS The development and evolutions of multiple domains of pediatric neurosurgery, including neuroimaging, hydrocephalus, pediatric brain tumor, spinal dysraphism, craniosynostosis, vascular malformation, functional neurosurgery and spinal disorders were reviewed and commented on based upon my own experience and reflection. RESULTS The field of pediatric neurosurgery has grown in all aspects of diagnosis and therapy owing to the introduction of computers, innovative techniques and technologies and new discoveries of scientific data including molecular investigations. CONCLUSION A minimally invasive approach and molecular target therapy are a current trend. The past half century's clinical experience and advances in biomedical knowledge and techniques provide foundation for further improvement in the care of children of the next generation. Prospective artificial intelligence will likely promote further advances in pediatric neurosurgery.
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Affiliation(s)
- Tadanori Tomita
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Chicago, Illinois, 60611, USA.
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Lynch BT, Montgomery BK, Verhofste BP, Proctor MR, Hedequist DJ. Two-Surgeon Multidisciplinary Approach to Pediatric Cervical Spinal Fusion: A Single-Institution Series and Review of the Literature. J Pediatr Orthop 2023; 43:392-399. [PMID: 36941115 DOI: 10.1097/bpo.0000000000002396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND A collaborative 2-surgeon approach is becoming increasingly popular in surgery but is not widely used for pediatric cervical spine fusions. The goal of this study is to present a large single-institution experience with pediatric cervical spinal fusion using a multidisciplinary 2-surgeon team, including a neurosurgeon and an orthopedic surgeon. This team-based approach has not been previously reported in the pediatric cervical spine literature. METHODS A single-institution review of pediatric cervical spine instrumentation and fusion performed by a surgical team composed of neurosurgery and orthopedics during 2002-2020 was performed. Demographics, presenting symptoms and indications, surgical characteristics, and outcomes were recorded. Particular focus was given to describe the primary surgical responsibility of the orthopedic surgeon and the neurosurgeon. RESULTS A total of 112 patients (54% male) with an average age of 12.1 (range 2-26) years met the inclusion criteria. The most common indications for surgery were os odontoideum with instability (n=21) and trauma (n=18). Syndromes were present in 44 (39%) cases. Fifty-five (49%) patients presented with preoperative neurological deficits (26 motor, 12 sensory, and 17 combined deficits). At the time of the last clinical follow-up, 44 (80%) of these patients had stabilization or resolution of their neurological deficit. There was 1 new postoperative neural deficit (1%). The average time between surgery and successful radiologic arthrodesis was 13.2±10.6 mo. A total of 15 (13%) patients experienced complications within 90 days of surgery (2 intraoperative, 6 during admission, and 7 after discharge). CONCLUSIONS A multidisciplinary 2-surgeon approach to pediatric cervical spine instrumentation and fusion provides a safe treatment option for complex pediatric cervical cases. It is hoped that this study could provide a model for other pediatric spine groups interested in implementing a multi-specialty 2-surgeon team to perform complex pediatric cervical spine fusions. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Benjamin T Lynch
- Department of Orthopaedic Surgery
- Department of Neurosurgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | | | - Bram P Verhofste
- Department of Orthopaedic Surgery
- Harvard Medical School, Boston, MA
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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5
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Liu HT, Liang ZH, Song J, Zhang HW, Zhou FC, Zhang QQ, Shao J, Zhang YH. Posterior Atlantoaxial Fusion With C1-2 Pedicle Screw Fixation for Atlantoaxial Dislocation in Pediatric Patients With Mucopolysaccharidosis IVA (Morquio a Syndrome): A Case Series. World Neurosurg 2023; 175:e574-e581. [PMID: 37028486 DOI: 10.1016/j.wneu.2023.03.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of posterior atlantoaxial fusion (AAF) with C1-2 pedicle screw fixation for atlantoaxial dislocation (AAD) in pediatric patients with mucopolysaccharidosis IVA (MPS IVA). METHODS This study included 21 pediatric patients with MPS IVA who underwent posterior AAF with C1-2 pedicle screw fixation. Anatomical parameters of the C1 and C2 pedicle were measured on preoperative computed tomography (CT). The American Spinal Injury Association (ASIA) scale was used to evaluate the neurological status. The fusion and accuracy of pedicle screw was assessed on postoperative CT. Demographic, radiation dose, bone density, surgical, and clinical data were recorded. RESULTS Patients reviewed included 21 patients younger than 16 years with an average age of 7.4 ± 4.2 years and an average of 20.9 ± 7.7 months follow-up. Fixation of 83 C1 and C2 pedicle screws was performed successfully and 96.3% of them were identified as being safe. One patient developed postoperative transient disturbance of consciousness and one developed fetal airway obstruction and died about 1 month after the surgery. Out of the remaining20 patients, fusion was achieved, symptoms were improved, and no other serious surgical complications were observed at the latest follow-up. CONCLUSIONS Posterior AAF with C1-2 pedicle screw fixation is effective and safe for AAD in pediatric patients with MPS IVA. However, the procedure is technically demanding and should be performed by experienced surgeons with strict multidisciplinary consultations.
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Affiliation(s)
- Hai-Tao Liu
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Hui Liang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Song
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui-Wen Zhang
- Department of Endocrinology and Genetics, Shanghai Institute of Pediatrics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Chao Zhou
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiu-Qi Zhang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Shao
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue-Hui Zhang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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6
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Compton E, Illingworth KD, Stephan S, Skaggs DL, Andras LM. Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement. Spine Deform 2023; 11:627-633. [PMID: 36745301 PMCID: PMC10147783 DOI: 10.1007/s43390-023-00641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 12/31/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions. METHODS Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed. RESULTS 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999). CONCLUSIONS The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis. STUDY DESIGN Retrospective, Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA
| | | | | | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA.
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7
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Chu ECP, Trager RJ, Tao C. Improvement of Chronic Neck Pain After Posterior Atlantoaxial Surgical Fusion via Multimodal Chiropractic Care: A Case Report. Cureus 2023; 15:e34630. [PMID: 36891015 PMCID: PMC9988189 DOI: 10.7759/cureus.34630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/07/2023] Open
Abstract
There is a lack of research regarding the effectiveness and safety of manual therapies, including spinal manipulative therapy (SMT), for patients with previous cervical spine surgery. A 66-year-old, otherwise healthy, woman who underwent C1/2 posterior surgical fusion for rotatory instability during adolescence presented to a chiropractor with a six-month history of progressive worsening of chronic neck pain and headaches despite acetaminophen, tramadol, and physical therapy. Upon examination, the chiropractor noted postural changes, limited cervical range of motion, and muscle hypertonicity. Computed tomography revealed a successful C1/2 fusion, and degenerative findings at C0/1, C2/3, C3/4, and C5/6, without cord compression. As the patient had no neurologic deficits or myelopathy and tolerated spinal mobilization well, the chiropractor applied cervical SMT, along with soft tissue manipulation, ultrasound therapy, mechanical traction, and thoracic SMT. The patient's pain was reduced to a mild level and the range of motion improved over three weeks of treatment. Benefits were maintained over a three-month follow-up as treatments were spaced apart. Despite the apparent success in the current case, evidence for manual therapies and SMT in patients with cervical spine surgery remains limited, and these therapies should be used with caution on an individual patient basis. Further research is needed to examine the safety of manual therapies and SMT in patients following cervical spine surgery and determine predictors of treatment response.
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Affiliation(s)
- Eric Chun-Pu Chu
- Department of Chiropractic and Physiotherapy, New York Chiropractic and Physiotherapy Centre, Kowloon, HKG
| | - Robert J Trager
- Chiropractic, Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Cliff Tao
- Radiology, Private Practice of Chiropractic Radiology, Irvine, USA
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8
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Spiessberger A, Newton PO, Mackenzie W, Samdani A, Miyanji F, Pahys J, Shah S, Sponseller P, Abel M, Phillips J, Marks M, Yaszay B. Posterior cervical spinal fusion in the pediatric population using modern adult instrumentation - clinical outcome and safety. Childs Nerv Syst 2023; 39:1573-1580. [PMID: 36688999 DOI: 10.1007/s00381-023-05834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/06/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE Traditionally, less rigid fixation techniques have been applied to the pediatric cervical spine. There is a lack of long-term outcome data for rigid fixation techniques. The purpose of this study was to define the clinical outcome and safety of posterior instrumented fusion in the pediatric population using adult posterior instrumentation. METHODS A multicenter, retrospective review of pediatric patients who underwent posterior cervical fusion using a 3.5 mm posterior cervical system for any indication was performed. Outcome parameters included complications, revision and fusion rates, operative time (OR), blood loss, and postoperative neurologic status. Outcomes were compared between patient groups (posterior only versus anterior/posterior approach, short versus intermediate versus long fusion, and between different etiologies) using Mann-Whitney and chi-square test. RESULTS Seventy-nine patients with a mean age of 9.9 years and mean follow-up of 2.8 years were included. At baseline 44 (56%) had an abnormal neurologic exam. Congenital deformities and basilar invagination were the most common indications for surgery. Posterior-only surgery was performed in 71 (90%) cases; mean number of levels fused was 4 (range 1-15). Overall, 4 (5%) operative complications and 4 (5%) revisions were reported at an average postoperative time of 2.6 years. Neurologic status remained unchanged in 74%, improved in 23%, and worsened in 3%. When comparing outcome measures between the various groups, 2 significant differences were found: OR was longer in the anterior/posterior approach group and decline of neuro status was more frequent in the long fusion group. CONCLUSION Posterior cervical fusion with an adult 3.5 mm posterior cervical system was safe in this cohort of 79 pediatric patients irrespective of surgical technique, fusion length, and etiology, resulting in a high fusion and low complication/revision rate.
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Affiliation(s)
- Alexander Spiessberger
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, USA
| | - Peter O Newton
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, USA
| | - William Mackenzie
- Spine and Scoliosis Center, Nemours Children's Hospital, Wilmington, DE, USA
| | - Amer Samdani
- Department of Orthopedics, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Firoz Miyanji
- Department of Orthopedics, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Joshua Pahys
- Department of Orthopedics, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Suken Shah
- Spine and Scoliosis Center, Nemours Children's Hospital, Wilmington, DE, USA
| | - Paul Sponseller
- Department of Orthopedics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Mark Abel
- Department of Orthopedics, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Jonathan Phillips
- Orlando Health Arnold Palmer Hospital for Children Center for Orthopedics, Orlando, FL, USA
| | - Michelle Marks
- Setting Scoliosis Straight Foundation, San Diego, CA, USA
| | - Burt Yaszay
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, M/S OA.9.120, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
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Dastagirzada YM, Alexiades NG, Kurland DB, Anderson SN, Brockmeyer DL, Bumpass DB, Chatterjee S, Groves ML, Hankinson TC, Harter D, Hedequist D, Jea A, Leonard JR, Martin JE, Oetgen ME, Pahys J, Rozzelle C, Strahle JM, Thompson D, Yaszay B, Anderson RCE. Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study. J Neurosurg Pediatr 2023; 31:32-42. [PMID: 36308472 DOI: 10.3171/2022.9.peds22319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Yosef M Dastagirzada
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - David B Kurland
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - David B Bumpass
- 5Department of Orthopedic Surgery, University of Arkansas, Little Rock, Arkansas
| | | | - Mari L Groves
- 7Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David Harter
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | - Daniel Hedequist
- 9Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Jea
- 10Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan E Martin
- 12Division of Pediatric Neurosurgery, Connecticut Children's, Hartford, Connecticut
| | - Matthew E Oetgen
- 13Division of Orthopedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC
| | - Joshua Pahys
- 14Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Curtis Rozzelle
- 15Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Jennifer M Strahle
- 16Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic Thompson
- 17Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Burt Yaszay
- 18Department of Orthopedics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Richard C E Anderson
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
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10
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Dastagirzada YM, Kurland DB, Hankinson TC, Anderson RCE. Craniovertebral Junction Instability in the Setting of Chiari Malformation. Neurosurg Clin N Am 2023; 34:131-142. [DOI: 10.1016/j.nec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Liang ZH, Zhang YH, Liu HT, Zhang QQ, Song J, Shao J. Comparison of structural occipital and iliac bone grafts for instrumented atlantoaxial fusions in pediatric patients: Radiologic research and clinical outcomes. Front Surg 2023; 10:1059544. [PMID: 37025272 PMCID: PMC10070866 DOI: 10.3389/fsurg.2023.1059544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
Background Structural autografts harvested from the iliac bone have been used in atlantoaxial fusion; they have been the gold standard for years. However, emerging occipital bone grafts have the advantage of avoiding donor-site morbidity and complications. Thus, we compared the clinical outcomes of structural autografts from the occipital bone or iliac crest and discussed the clinical significance of occipital bone grafts in pediatric patients. Methods Pediatric patients who underwent posterior fusion using occipital bone grafts (OBG) or iliac bone grafts (IBG) between 2017 and 2021 were included in this study. Data on clinical outcomes, including operation time, estimated blood loss, length of hospitalization, complications, fusion rate, and fusion time, were collected and analyzed. Additionally, 300 pediatric patients who underwent cranial computed tomography scans were included in the bone thickness evaluation procedure. The central and edge thicknesses of the harvested areas were recorded and analyzed. Results Thirty-nine patients were included in this study. There were no significant differences in patient characteristics between the OBG and IBG groups. Patients in both groups achieved a 100% fusion rate; however, the fusion time in the OBG group was significantly longer than that in the IBG group. Estimated blood loss, operation time, and length of hospitalization were significantly lower in the OBG group than those in the IBG group. The surgery-related complication rate was lower, but not significantly, in the OBG group than that in the IBG group. For occipital bone thickness evaluation, a significant difference in the central part of the harvesting area was found between the young and old groups, with no significant sex differences. Conclusion The use of OBG for atlantoaxial fusion is acceptable for pediatric patients with atlantoaxial dislocation, avoiding donor-site morbidity and complications.
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Affiliation(s)
| | | | | | | | | | - Jiang Shao
- Correspondence: Yue-Hui Zhang Jiang Shao
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12
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Zairi M, Msakni A, Mohseni AA, Nessib N, Bouali S, Boussetta R, Nessib MN. Cranio-cervical decompression associated with non-instrumented occipito-C2 fusion in children with mucopolysaccharidoses: Report of twenty-one cases. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100183. [PMID: 36458130 PMCID: PMC9706171 DOI: 10.1016/j.xnsj.2022.100183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Mucopolysaccharidosis (MPS) is a multisystemic storage disorder of glycosaminoglycan deposits. Infiltration of the dura mater and supporting ligaments caused spinal cord compression and consecutive myelopathy, especially at the cranio-cervical junction (CCJ). Craniocervical instability and posterior decompression often raise the problem of fixation in children. The main purpose of this paper was to report the result of an original technique of occipito-cervical arthrodesis using a cranial halo-cast system in pediatric population. METHODS We recorded 21 patients with cervical myelopathy. All of them had spinal cord decompression by enlargement of the foramen magnum, C1 laminectomy, and occipito-C2 fusion using corticocancellous bone graft. Only one child has an extended laminectomy from C1 to C3. The occiput-C2 arthrodesis was stabilized by the cranial halo-cast system. This immobilization was performed preoperatively and kept for three months then switched to rigid cervical collar. Clinical assessment, including the Goel grade and mJOA, radiographs and magnetic resonance imaging were performed before surgery. The occipito-cervical arthrodesis was controlled by standard X-rays and CT scan. RESULTS According to the type of mucopolysaccharidosis, the patients were divided into MPS type I: n= 3, II: n=7, IV: n=11. The mean age of patients at surgery was 6.76 years. All mucopolysaccharidoses cases required a foramen magnum decompression by craniectomy, C1 laminectomy and occipito-C2 arthrodesis. As major complications, a child had immediate post-operative paraplegia due to spinal cord ischemia. The postoperative follow-up ranged from 1.5 to 4 years, with an average of 3.3 years. The average preoperative mJOA score was 8.9, and it improved to 14 points at the last follow-up. CONCLUSIONS Satisfactory fusion and good clinical results were obtained with the 2-stage approach to CCJ anomalies.
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Affiliation(s)
- Mohamed Zairi
- Faculty of Medicine of Tunis, Department of Pediatric Orthopedic Surgery, Bechir Hamza Children's Hospital, Tunis, Tunisia
| | - Ahmed Msakni
- Faculty of Medicine of Tunis, Department of Pediatric Orthopedic Surgery, Bechir Hamza Children's Hospital, Tunis, Tunisia
| | - Ahmed Amin Mohseni
- Faculty of Medicine of Tunis, Department of Pediatric Orthopedic Surgery, Bechir Hamza Children's Hospital, Tunis, Tunisia
| | - Nesrine Nessib
- Faculty of Medicine of Tunis, Department of Neurosurgery, National Institute of Neurology, Tunis, Tunisia
| | - Sofiene Bouali
- Faculty of Medicine of Tunis, Department of Neurosurgery, National Institute of Neurology, Tunis, Tunisia
| | - Rim Boussetta
- Faculty of Medicine of Tunis, Department of Pediatric Orthopedic Surgery, Bechir Hamza Children's Hospital, Tunis, Tunisia
| | - Mohamed Nabil Nessib
- Faculty of Medicine of Tunis, Department of Pediatric Orthopedic Surgery, Bechir Hamza Children's Hospital, Tunis, Tunisia
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Pediatric craniocervical fusion: predictors of surgical outcomes, risk of recurrence, and re-operation. Childs Nerv Syst 2022; 38:1531-1539. [PMID: 35511272 DOI: 10.1007/s00381-022-05541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Craniocervical junction abnormalities include a wide variety of disorders and can be classified into congenital or acquired. This study aimed to review the surgical outcome of pediatric patients who underwent craniocervical and/or atlantoaxial fusion. METHODS This is a retrospective cohort study including all pediatric patients (≤ 18 years) who underwent craniocervical and/or atlantoaxial fusion between 2009 and 2019 at quaternary medical city. RESULTS A total of 25 patients met our criteria and were included in the study. The mean age was 9 years (range: 1-17 years). There was a slight female preponderance (N = 13; 52%). Most patients (N = 16; 64%) had non-trauamatic/chronic causes of craniocervical instability. Most patients presented with neck pain and/or stiffness (N = 14; 56%). Successful fusion of the craniocervical junction was achieved in most patients (N = 21; 84%). Intraoperative complications were encountered in 12% (N = 3) of the patients. Early postoperative complications were observed in five patients (20%). Five patients (20%) experienced long-term complications. Revision was needed in two patients (8%). Older age was significantly associated with higher fusion success rates (p = 0.003). The need for revision surgery rates was significantly higher among younger age group (3.75 ± 2, p = 0.01). CONCLUSIONS The study demonstrates the surgical outcome of craniocervical and/or atlantoaxial fusion in pediatric patients. Successful fusion of the craniocervical junction was achieved in most patients. Significant association was found between older age and successful fusion, and between younger age and need for revision surgery.
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Anterior Transarticular Crossing Screw Placement for Atlantoaxial Instability in Children: Computed Tomography-Based Study. World Neurosurg 2022; 161:e192-e198. [PMID: 35183796 DOI: 10.1016/j.wneu.2022.01.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The feasibility of anterior transarticular crossing screw (ATCS) fixation for atlantoaxial instability was confirmed in adults. However, atlantoaxial instability is more common in children. Therefore this study was aimed to ascertain the pediatric morphometric characteristics of ATCS in C1-2. METHODS Morphometric analysis was conducted on computed tomography scan in 87 pediatric patients who were divided into groups based on ages (1-6 years, 7-10 years, and 11-16 years). Measurements were taken in sagittal and axial planes of computed tomography imaging to determine the range of screw lateral angles, incline angles, and screw lengths. RESULTS The overall screw lengths were relatively longer in males than females. For those aged 1-6 years, the screw lengths were 25.5-32.8 mm in males and 24.2-31.3 mm in females, respectively. The screw lengths showed no difference in the 7- to 10-year group between sexes, while the incline angle was larger in females than males. And the screw lengths were 33.5-43.2 mm in males and 31.2-40.4 mm in females in the 11- to 16-year group. The screw lengths were increased with age, yet the lateral angles were decreased. We also found that the epiphyseal closure of odontoid reached 93.6% when the age was older than 7 years old. Therefore ATCS was recommended for children older than 7 years. CONCLUSIONS The overall screw lengths and lateral angles of ATCS were larger in male children than those in females, but the incline angles were larger in females. ATCS is feasible in children, particularly those aged 7 years or older.
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Singh D, Pathak V, Singh N, Singh R, Kaif M, Yadav K. C1 lateral mass reduction screws for treating atlantoaxial dislocations: Bringing ease by modification. J Craniovertebr Junction Spine 2022; 13:140-145. [PMID: 35837430 PMCID: PMC9274681 DOI: 10.4103/jcvjs.jcvjs_8_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/25/2022] [Indexed: 11/04/2022] Open
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Orthopaedic Management of Loeys-Dietz Syndrome: A Systematic Review. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202111000-00005. [PMID: 34779796 PMCID: PMC8594655 DOI: 10.5435/jaaosglobal-d-21-00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022]
Abstract
Introduction: Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder associated with aortic aneurysm/dissection in children. However, LDS may also present with a host of orthopaedic conditions. This study aimed to elucidate the management of orthopaedic conditions and associated outcomes in patients with LDS. Methods: PubMed, Ovid MEDLINE, and Cochrane Library were systematically searched for primary articles regarding the management of orthopaedic conditions in patients with LDS. The goals and findings of each included study were described. Data regarding demographics, conditions studied, treatment modalities, and outcomes were extracted and analyzed. Results: Three hundred sixty-two unique articles were retrieved, 13 of which were included, with 4 retrospective cohort studies and 9 case reports representing 435 patients. In total, 19.8% of patients presenting with orthopaedic conditions received surgical treatment;54.3% of them experienced adverse outcomes, and 44.4% required revision surgery. The mean age at surgery was 9.0 ± 2.1 years. Conclusion: Patients with LDS may require early surgical intervention for a variety of orthopaedic conditions and may be at an increased risk for surgical complications. The current LDS literature is primarily focused on spinal conditions with a relative paucity of data on the management of hip deformity, joint subluxation, clubfoot, and trauma. Additional research is required regarding orthopaedic management for this unique population.
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Goparaju PVNR, Rangnekar A, Chigh A, Raut SS, Kundnani V. Safety, efficacy, surgical, and radiological outcomes of short segment occipital plate and C2 transarticular screw construct for occipito-cervical instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:381-386. [PMID: 35068820 PMCID: PMC8740813 DOI: 10.4103/jcvjs.jcvjs_113_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: Our study aims to assess the safety, efficacy, clinicoradiological, functional, neurological outcomes, and complications of posterior occipitocervical fixation using an occipital plate and C1-2 transarticular screw (TAS) construct. Study Design: This was a retrospective analysis of prospectively collected data. Methods: Data of 27 patients who underwent occipital plate and C1-2 TAS construct at a single institute from 2010 to 2015 were collected and analyzed. Demographics, clinical parameters (Visual Analog Score, Oswestry Disability Index, and modified JOA score), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical-2 angle, surgical parameters (operative time, blood loss, hospital stay, and fusion), and complications were evaluated. Results: The mean age of the patients was 54.074 ± 16.52 years (18–81 years), the mean operative time was 116.29 ± 12.23 min, and the mean blood loss was 196.29 ± 38.94 ml. The mean hospital stay was 5.22 ± 1.28 days. The mean ± standard deviation follow-up duration was 62.52 ± 2.27 months. There was a significant improvement in clinical parameters and radiological parameters postoperatively. One patient with implant failure, one patient with pseudoarthrosis, one with neurological deterioration, two wound complications, and two dural tears were noted. Conclusion: Posterior occipitocervical reconstruction with O-C1-2 TAS construct provided excellent clinical outcomes, radiological outcomes, optimal correction of malalignment in the occipitocervical region, and with biomechanically sound fixation. Extending the instrumentation into the subaxial spine will lead to a decrease in the range of motion, increased surgical time, blood loss, more extensive muscle damage, and also increase the costs.
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Affiliation(s)
- Praveen V N R Goparaju
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ameya Rangnekar
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Amit Chigh
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Saijyot Santosh Raut
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vishal Kundnani
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Burkhardt BW, Podolski W, Pitzen TR, Ruf M. The Feasibility of C1-C2 Screw-rod Fixation in the Children 5 Years of Age and Younger. J Pediatr Orthop 2021; 41:e651-e658. [PMID: 34238864 DOI: 10.1097/bpo.0000000000001899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Atlantoaxial fixation is technically challenging in younger children. The C1-C2 screw-rod fixation technique is established for adults but limited data about the clinical and radiographical outcome for the treatment of children with 5 years of age or younger is available. METHODS All files of children who were consecutively treated for spinal disorders were reviewed. Inclusion criteria for further evaluation were: 0 to 5 years of age at initial procedure; detailed surgical report of a posterior C1-C2 fusion with mass lateral and pedicle screw-rod fixation as described by Harms; a minimum clinical and radiographical follow-up of 24 months. The postoperative and last follow-up computed tomography scan and radiographs were used to assess the positioning and stability of the C1-C2 screw-rod construct. RESULTS Eleven patients (3 boys) with a mean age of 46 months (range: 8 to 66 mo) fulfilled inclusion criteria and were evaluated retrospectively. The mean clinical and radiographical follow-up was 79 months (range: 24 mo to 170 mo). The diagnosis was atlantoaxial rotatory dislocation (4 cases), C1-C2 instability with subluxation (3 cases), atlantoaxial dislocation and os odontoideum (1 case), type II odontoid fracture (1 case), traumatic odontoid epiphysiolysis (1 case), and traumatic rupture of the transverse ligament with C1 subluxation (1 case). Intraoperatively and postoperatively no new neurovascular or vascular complication occurred. C1 lateral mass screws were placed correctly in all cases. Twenty-two C2 pedicle screws were placed correctly (85.7%), and 3 screws showed penetration of the pedicle wall (14.3%). No implant revision, implant failure, and pseudarthrosis were noted. Loss of correction was noted in 1 patient with unilateral C1-C2 fixation and a repeated dorsal fusion procedures were performed. A repeat procedure for implant removal and segmental release was performed in 3 patients to increase the axial rotation of the head. CONCLUSIONS The C1-C2 screw-rod fixation is a safe technique that achieves solid fixation of the atlantoaxial complex in young children with various disorders. The technique preserves the joint and allows for segmental release via implant removal.
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Affiliation(s)
- Benedikt W Burkhardt
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg-Saar
| | - Wladislaw Podolski
- Center for Spine Surgery, Orthopedics and Traumatology, SRH-Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Tobias R Pitzen
- Center for Spine Surgery, Orthopedics and Traumatology, SRH-Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Michael Ruf
- Center for Spine Surgery, Orthopedics and Traumatology, SRH-Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
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The technique of using three-dimensional and multiplanar reformatted computed tomography for preoperative planning in pediatric craniovertebral anomalies. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 7:100073. [PMID: 35141638 PMCID: PMC8819977 DOI: 10.1016/j.xnsj.2021.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 11/23/2022]
Abstract
Surgical planning of pediatric craniovertebral anomalies is requires multiplanar CT reconstructions. Screw trajectories can be planned in 4 steps using an open-source DICOM manipulation software. This method gives more anatomical information compared to studying conventional PACS images.
Background Computed tomography (CT) images provided by the radiology department may be inadequate for planning screws for rigid craniovertebral junction (CVJ) instrumentation. Although many recommend using multiplanar reconstruction (MPR) in line with screw trajectories, this is not always available to all surgeons. The current study aims to present a step-by-step workflow for preoperative planning for pediatric CVJ anomalies. Methods Twenty-five consecutive children (<12 years) were operated for atlantoaxial instability between 2014 and 2019. Preoperative CT angiograms were transferred to an open-source software called Horos™. The surgeon manipulated images in this viewing software to determine an idealized path of screws. Three-dimensional volume rendering of the pathoanatomy was generated, and anomalies were noted. The surgeon compared the anatomical data obtained using Horos™ with that from the original imaging platform and graded it as; Grade A (substantial new information), Grade B (confirmatory with improved visualization and understanding), Grade C (no added information). The surgeon then executed the surgical plan determined using Horos™. Results Surgeries performed were occipitocervical (n = 18, 72%) and atlantoaxial fixation (n = 7, 28%) at a mean age of 7.2 years, with 72% of etiologies being congenital or dysplasias. In 18 (72%) patients, the surgeon noted substantial new information (Grade A) about CVJ anomalies on Horos™ compared to original imaging platform. Concerning planning for fixation anchors, the surgeon graded A in all patients (100%). In 4 (16%) patients, the surgery could not be executed precisely as planned. There were three (12%) complications; VA injury (n = 1), neurological worsening (n = 1), and loss of fixation (n = 1). Conclusion In our experience, surgeon-directed imaging manipulation gives more anatomical information compared to studying original imaging planes and should be incorporated in the surgeon's preoperative workup. When image reformatting options are limited, open-source software like Horos™ may offer advantages.
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Feasibility and Safety of Goel-Harms Posterior C1-C2 Fusion in the Management of Pediatric Reducible Atlantoaxial Instability. World Neurosurg 2021; 155:e592-e599. [PMID: 34464778 DOI: 10.1016/j.wneu.2021.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pediatric atlantoaxial instability (AAI) is not common and could be a serious clinical condition. The Goel-Harms technique is one of the most used techniques in adults and needs more evaluation in pediatric populations. This study reports the feasibility and safety of the Goel-Harms technique in the treatment of pediatric reducible AAI. METHODS In this retrospective cohort study we reported all pediatric patients who underwent Goel-Harms technique for AAI with a minimum 1-year follow up. Patients were clinically assessed using the Japanese Orthopedic Association (JOA) score and radiologically with plain radiographs, computed tomography scan, and magnetic resonance imaging of the craniocervical region. Postoperatively, patients were followed up according to our clinical and radiographic imaging protocol. The following parameters were recorded: JOA score, construct stability, fusion, and abnormal events. RESULTS A total of 25 patients have completed a 1-year follow-up and fulfilled our criteria. The mean age was 10.68 ± 4.47 (range, 3-17) years. Fifteen patients were male and 10 were female. The final diagnosis included Down syndrome (DS) in 8, type II dens fracture in 7, os odontoideum in 3, and atlantoaxial rotatory fixation in 7. The mean follow-up was 21.76 ± 8.22 months. The preoperative JOA score improved from 15.96 ± 1.46 to 16.76 ± 1.92 at the last follow-up. Sound bone fusion was reported in 92% of patients. CONCLUSIONS Our data suggest that the Goel-Harms technique is a safe, feasible, and effective procedure in managing pediatric reducible AAI. Special perioperative care should be offered to young AAI patients with DS.
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21
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Pijpker PAJ, Kuijlen JMA, Kaptein BL, Pondaag W. Three-Dimensional-Printed Drill Guides for Occipitothoracic Fusion in a Pediatric Patient With Occipitocervical Instability. Oper Neurosurg (Hagerstown) 2021; 21:27-33. [PMID: 33728473 PMCID: PMC8203425 DOI: 10.1093/ons/opab060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/25/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pediatric occipitothoracic fusion can be challenging because of small size pedicles and thin occipital bone. Three-dimensional (3D) printing technology can help with accurate screw insertion but has not been described for occipital keel plate positioning so far. OBJECTIVE To describe the novel use of 3D technology to position occipital keel plates during pediatric occipitothoracic fixation. METHODS A young boy with segmental spinal dysgenesis presented with asymmetrical pyramidal paresis in all limbs. Developmental abnormities of the cervical spine caused a thinned spinal cord, and because of progressive spinal cord compression, surgical intervention by means of occipitothoracic fixation was indicated at the age of 3 yr.Because of the small-size pedicles and thin occipital bone, the pedicle screws and occipital plates were planned meticulously using 3D virtual surgical planning technology. The rods were virtually bent in order to properly align with the planned screws. By means of 3D-printed guides, the surgical plan was transferred to the operating theater. For the occipital bone, a novel guide concept was developed, aiming for screw positions at maximal bone thickness. RESULTS The postoperative course was uneventful, and radiographs showed good cervical alignment. After superimposing the virtual plan with the intraoperative acquired computed tomography, it was confirmed that the occipital plate positions matched the virtual plan and that pedicle screws were accurately inserted without signs of breach. CONCLUSION The use of 3D technology has greatly facilitated the performance of the occipitothoracic fixation and could, in the future, contribute to safer pediatric spinal fixation procedures.
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Affiliation(s)
- Peter A J Pijpker
- 3D lab, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jos M A Kuijlen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bart L Kaptein
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
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Gadgil N, Rao G, Sawaya R, Yoshor D, Ruggieri L, Cormier N, Curry DJ, Whitehead WE, Aldave G, Bauer DF, McClugage S, Weiner HL. Pediatric neurosurgery at Texas Children's Hospital: the legacy of Dr. William R. Cheek. J Neurosurg Pediatr 2021; 28:86-92. [PMID: 33962381 DOI: 10.3171/2020.10.peds20807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022]
Abstract
Texas Children's Hospital opened its doors in 1954, and since that time the institution has remained dedicated to a three-part mission: patient care, education, and research. Dr. William R. Cheek developed an early interest in pediatric neurosurgery, which led to his efforts in building and developing a service at Texas Children's Hospital at a time when the field was just emerging. His work with other early pioneers in the field led to the establishment of organized societies, educational texts, and governing bodies that have led to significant advances in the field over the past 50 years.
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Affiliation(s)
- Nisha Gadgil
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Ganesh Rao
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Raymond Sawaya
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Daniel Yoshor
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lucia Ruggieri
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Natalie Cormier
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Daniel J Curry
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - William E Whitehead
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Guillermo Aldave
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - David F Bauer
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Samuel McClugage
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
| | - Howard L Weiner
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital; and
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Dhawale A, Bajaj S, Chaudhary K, Agarwal T, Garg S, Choudhury H. Posterior Circulation Stroke due to Atlantoaxial Instability in CHST3-Related Skeletal Dysplasia: A Case Report. JBJS Case Connect 2021; 11:01709767-202103000-00034. [PMID: 33625031 DOI: 10.2106/jbjs.cc.20.00393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE An eight-year-old boy presented with acute encephalopathy due to posterior circulation ischemic stroke. He was found to have vertebral artery stenosis secondary to atlantoaxial instability (AAI) due to an os odontoideum. Occipitocervical fusion was performed 4 weeks after stroke. The child improved neurologically and regained independent ambulation. He had indications of an underlying spondyloepiphyseal dysplasia with joint luxation and whole-exome sequencing diagnosed CHST3-related skeletal dysplasia. CONCLUSION As far as we know, this AAI due to an os odontoideum is a previously unreported complication of CHST3-related skeletal dysplasia. Occipitocervical fusion yielded good clinical results with the 1-year follow-up.
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Affiliation(s)
- Arjun Dhawale
- Department of Orthopaedics, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
| | - Shruti Bajaj
- Department of Pediatrics, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
| | - Kshitij Chaudhary
- Department of Orthopaedics, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
| | - Tushar Agarwal
- Department of Orthopaedics, Bhaktivedanta Hospital and Research Institute, Thane, Maharashtra, India
| | - Sandeep Garg
- Department of Pediatrics, Bhaktivedanta Hospital and Research Institute, Thane, Maharashtra, India
| | - Himanshu Choudhury
- Department of Radiology, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
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Abstract
BACKGROUND Occipital plate fixation has been shown to improve outcomes in cervical spine fusion. There is a paucity of literature describing occipital plate fixation, especially in the pediatric population. The authors reviewed a case series of 34 patients at a pediatric hospital who underwent cervical spine fusion with occipital plate fixation between 2003 and 2016. This study describes how occipital plates aid the cervical spine union in a case series of diverse, complex pediatric patients. METHODS Our orthopaedic database at our institution was queried for patients undergoing an instrumented cervical spine procedure between 2003 and 2016. Medical records were used to collect diagnoses, fusion levels, surgical technique, and length of hospitalization, neurophysiological monitoring, complications, and revision procedures. RESULTS Thirty-four patients met the inclusion criteria. The mean age was 10.9 years (range, 3-21 y). Indications for surgery included cervical instability, basilar invagination, and os odontoideum. These indications were often secondary to a variety of diagnoses, including trisomy 21, Klippel-Feil syndrome, and rheumatoid arthritis. The mean length of hospitalization was 10 days (range, 2 to 80 d). There were no cases of intraoperative dural leak, venous sinus bleeding from occipital screw placement, or implant-related complications. Postoperative complications included 2 cases of nonunion. Eight patients (24%) had follow-up surgery, only 3 (9%) of which were instrumentation revisions. Both patients with nonunion had repeat occipitocervical fixation procedures and achieved union with revision. CONCLUSIONS Occipital plate fixation was successful for pediatric cervical spine fusion in this diverse cohort. The only procedure-related complication demonstrated was delayed union or nonunion and implant loosening (4/34, 12%) and there were no plate-related complications. This novel case series shows that occipital plate fixation is safe and effective for pediatric patients with complex diagnoses. LEVEL OF EVIDENCE Level IV-case series.
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Posterior Direct Reduction of Lateral Atlantoaxial Joints for Rigid Pediatric Atlantoaxial Subluxation: A Fulcrum Lever Technique. Spine (Phila Pa 1976) 2020; 45:E1119-E1126. [PMID: 32355147 DOI: 10.1097/brs.0000000000003510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Clinical case series. OBJECTIVE To present a surgical technique and results of posterior direct reduction of lateral atlantoaxial joints for rigid pediatric atlantoaxial subluxation (AAS) using a fulcrum lever technique. SUMMARY OF BACKGROUND DATA The surgical treatment of pediatric rigid AAS is still technically challenging. Several factors contribute to the surgical difficulty, such as small vertebrae, incomplete bone formation, dysplasia, the difficulty of reduction and external fixation are considered as a surgical daunting challenge. Herein, the surgical technique of posterior direct reduction of lateral atlantoaxial joints for rigid pediatric AAS using a fulcrum lever technique is presented. METHODS This retrospective study included 10 pediatric patients with rigid AAS who underwent posterior direct reduction of bilateral C1/2 facet joints via a fulcrum lever technique. The indication for surgery was the presence of neurological symptoms and spinal cord atrophy with an intramedullary high signal at the C1 level on T2-weighted magnetic resonance (MR) images. The surgical procedure consisted of three steps: (1) opening and distraction of the C1/2 facet joints and placement of tricortical bone as a spacer and fulcrum; (2) placement of C1 and C2 screws; and finally, (3) compression between the C1 posterior arch and C2 lamina and constructing C1/2 fusion. All patients underwent the neurological and radiological evaluations before and after surgery. RESULTS Eight of 10 patients demonstrated genetic disorders, either Down syndrome or chondrodysplasia punctate. Besides, all cases documented congenital anomaly of the odontoid process. Bilateral C1 lateral mass screws were successfully placed in all cases. No evidence of postoperative neurovascular complications. Radiological evaluation showed the corrections and bony fusions of C1/2 facet joint in all cases. CONCLUSION The fulcrum lever technique for rigid pediatric AAS can be one of the effective surgical solutions to this challenging pediatric spinal disorder. LEVEL OF EVIDENCE 4.
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Abstract
BACKGROUND The use of modern rigid instrumentation in pediatric cervical fusions decreases the risk of implant-related complications, both acute and long term. However, previous studies have indicated that acute implant-related issues still occur in the adult population. Reports of pediatric acute implant complications, occurring within 3 months of surgery, are under-represented in the literature. The purpose of this study is to document the prevalence of acute implant-related complications in a pediatric cervical fusion population. METHODS A retrospective review of instrumented cervical fusions from August 2002 to December 2018 was conducted. Acute implant-related complications were defined as malposition, fracture, or disengagement of cervical instrumentation, including screws, rods, and plates, within 90 days of surgery. RESULTS A total of 166 cases were included (55% male individuals) with an average age at surgery of 12.5 years (SD, ±5.28). Acute implant-related complications occurred in 5 patients (3%). All 5 patients had a syndromic diagnosis: Loeys-Dietz (n=1), osteopetrosis (n=1), neurofibromatosis (n=1), trisomy 20 (n=1), and achondroplasia (n=1). One case involved asymptomatic screw protrusion, 1 case lateral mass screw pull-out, 2 more had screw-rod disengagement, and the last experienced dislodgement of the anterior plate. The median time until the presentation was 25 days (range, 1 to 79 d). All patients (n=5) required surgical revision. CONCLUSIONS This case series suggests that the overall incidence of acute cervical implant failure is low. However, failure is more likely to occur in patients with underlying syndromes compared with patients with different etiologies. Intraoperative use of 3-dimensional computed tomography imaging is recommended to evaluate the screw position and potentially avoid later surgery.
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Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis. Acta Neurochir (Wien) 2020; 162:1553-1563. [PMID: 32504118 PMCID: PMC7295832 DOI: 10.1007/s00701-020-04429-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 12/27/2022]
Abstract
Introduction Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability. Methods The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature. Conclusion The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.
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Abstract
INTRODUCTION Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. METHODS A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. RESULTS A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. CONCLUSIONS Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. LEVEL OF EVIDENCE Level IV.
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Surgical Fixation Using Screw-Rod Construct Instrumentation for Upper Cervical Instability in Pediatric Down Syndrome Patients. Spine Deform 2019; 7:957-961. [PMID: 31732008 DOI: 10.1016/j.jspd.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/31/2019] [Accepted: 03/08/2019] [Indexed: 11/20/2022]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES To describe the indications and outcomes of cervical fixation using modern instrumentation in a case series of pediatric Down syndrome (DS) patients. SUMMARY OF BACKGROUND DATA Cervical instability is the major cervical spine concern in children with DS. Although fixation techniques have advanced over the past quarter-century, the outcome of fixation with modern instrumentation for upper cervical instability in DS patients has not been thoroughly investigated. METHODS We searched the orthopedic database at our institution for patients with a diagnosis of DS who had undergone a cervical spine fusion between 2006 and 2017. Patient demographics, diagnoses, surgical indications, surgical details, and complications were recorded. Preoperative imaging was reviewed to determine atlanto-dens intervals and spinal cord signal changes. Postoperative radiographs or CT scans were reviewed to determine union. RESULTS Twelve DS patients met our inclusion criteria. The mean age at surgery was 9.3 years (range 3.8-18.8 years). Patients with secondary causes of instability included 7 patients with os odontoideum and 1 patient with a pars fracture. Three patients (25%) were identified on asymptomatic screening, with none of these having cord signal changes on magnetic resonance imaging (MRI). Modern implants (screws, plates, cages) were used in every patient in our series. The mean number of levels fused was 1.9 (range 1-5). The overall complication rate was 41.7% (5/12). Four patients required repeat surgery for nonunion. All patients with adequate radiographic follow-up demonstrated union (11/11, 100%). One patient was lost to follow-up. CONCLUSIONS Fixation for cervical instability is a critical component of the management of DS. A minority of patients receiving surgery were identified through asymptomatic screening. There was a high complication risk associated with surgery in our study; however, the addition of rigid fixation has lessened the complication rate compared with previous studies. LEVEL OF EVIDENCE Level IV.
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Efficacy and Safety of Atlantoaxial Fluoroscopy-guided Pedicle Screw Fixation in Patients Younger Than 12 Years: A Radiographic and Clinical Assessment. Spine (Phila Pa 1976) 2019; 44:1412-1417. [PMID: 31589199 DOI: 10.1097/brs.0000000000003139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective clinical study. OBJECTIVE The aim of this study was to evaluate the efficacy and safety of fluoroscopy-guided atlantoaxial pedicle screw fixation in patients younger than 12 years. SUMMARY OF BACKGROUND DATA C1-C2 pedicle screw fixation is a widely accepted treatment method for atlantoaxial dislocation (AAD). However, data regarding its use for atlantoaxial fusion (AAF) in children are limited. METHODS Thirty-six consecutive patients younger than 12 years underwent C1-C2 pedicle screw fixation for AAD between 2007 and 2017. Anatomical parameters of the C1 pedicle were measured on preoperative computed tomography (CT). Accuracy of pedicle screw fixation was assessed on postoperative CT using the following definitions: Type I, screw threads completely within the bone; Type II, less than half the diameter of the screw violating the surrounding cortex; and Type III, clear violation of the transverse foramen or spinal canal. Demographic, surgical, radiation dose, and clinical data were recorded. RESULTS Patients underwent 144 screw fixations (67 C1 pedicle screws, 68 C2 pedicle screws, 5 C1 lateral mass screws, and 4 C-2 laminar screws) for a variety of pediatric AADs, with 36.5 ± 8.5 months of follow-up. Among the 135 pedicle screws, 96.3% were deemed "safe" (Type I or II) and 80.7% (109/135) of the screws were rated as being ideal (Type I); five screws (3.7%) were identified as unacceptable (Type III). Average estimated blood loss (EBL) was 92 mL, and the average total radiation exposure during the operation was 6.2 mGy (in the final 26 cases). There were no neurovascular injuries. All patients showed radiographic stability and symptom resolution. CONCLUSION C1-C2 pedicle screw fixation under fluoroscopy is safe and effective for the treatment of AAD in children younger than 12 years. However, it may be technically challenging owing to the special anatomical features of children and should be performed by experienced surgeons. LEVEL OF EVIDENCE 3.
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Nonmetallic posterior monosegmental cervical fusion of a dislocated C6/7 fracture in a 4-year-old girl : A case report. DER ORTHOPADE 2019; 48:433-439. [PMID: 30887057 DOI: 10.1007/s00132-019-03714-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Pediatric cervical spine injuries constitute approximately 1-2% of all pediatric trauma cases. Usually pediatric vertebral injuries appear as stable A type fractures, whereas B and C type injuries are relatively uncommon. In contrast to adults, the appropriate treatment strategy in children is still controversial and places spine surgeons in complex situations. This article reports the case of a 4-year-old girl with an unstable B type injury at the C6/7 level (AOSpine C6-7: B2 [F4 BL, C7:A1]) with bilateral locked fractures of the facet joints after falling down a flight of stairs. PATIENT AND METHODS Magnetic resonance imaging (MRI) and computed tomography (CT) were initially performed. The 4‑year-old girl was treated under intraoperative neurophysiological monitoring via open reduction after partial resection of both C7 upper articular processes and nonmetallic monosegmental posterior interlaminar fusion (FiberWire®) at the C6/7 level with temporary immobilization in a halo brace. RESULTS Clinical and radiological follow-up was carried out after 9 months. The patient suffered no pain or neurological deficits. Plain radiographs revealed a correct cervical alignment with anatomical correction of the initial dislocation. CONCLUSION The treatment of highly unstable pediatric B type injuries of the lower cervical spine via open reduction and nonmetallic monosegmental posterior interlaminar fusion results in good clinical and radiological outcomes. A temporary immobilization in a halo brace provides stability until osseous fusion occurs.
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Verhofste BP, Glotzbecker MP, Hresko MT, Miller PE, Birch CM, Troy MJ, Karlin LI, Emans JB, Proctor MR, Hedequist DJ. Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions. J Neurosurg Pediatr 2019; 24:528-538. [PMID: 31419801 DOI: 10.3171/2019.5.peds19200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion. METHODS A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms. RESULTS A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07). CONCLUSIONS An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.
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Affiliation(s)
- Bram P Verhofste
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael P Glotzbecker
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael T Hresko
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Patricia E Miller
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Craig M Birch
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael J Troy
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Lawrence I Karlin
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - John B Emans
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Mark R Proctor
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Daniel J Hedequist
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
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Occipitocervical or C1-C2 fusion using allograft bone in pediatric patients with Down syndrome 8 years of age or younger. J Pediatr Orthop B 2019; 28:405-410. [PMID: 30855547 DOI: 10.1097/bpb.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sufficient internal fixation for occipitocervical (OC) or C1-C2 instability in pediatric patients with Down syndrome is difficult owing to small osseous structures, congenital deformities, and immature ossification. The purpose of this study was to evaluate the clinical outcomes of patients aged 8 years or younger with Down syndrome who underwent OC or C1-C2 fusion using freeze-dried allograft as bone graft substitute. The participants included seven consecutive patients aged 8 years or younger with Down syndrome who were treated for upper cervical disorders with posterior OC or C1-C2 fusion using freeze-dried allografts at our hospital between 2007 and 2016 and had a minimum follow-up of 1 year. Postoperative flexion/extension cervical radiography and computed tomography were repeated at 3 months after surgery before removal of the collar. The modified McCormick scale was used to grade functional status. The seven patients had an age range of 5-8 years (mean: 5.9 years). The mean follow-up period was 36 months (12-120 months). Six patients had os odontoideum and one had basilar invagination. Three patients underwent C1-C2 fusion, and in all cases, bilateral C1 lateral mass screws and bilateral C2 pedicle screws were used. Four patients underwent OC fusion, and in three of these cases, occipital and bilateral pedicle screws were used. One patient underwent reoperation because of occipital screw back-out with autograft; therefore, C2 lamina screws were added to pedicle screws. Solid bony fusion was achieved, and stable constructs were maintained on radiography in all patients, without infection or implant failure. In this study, we used freeze-dried allograft as a bone graft substitute, and we were able to detect bony trabeculae at the graft-recipient interface on lateral cervical radiographs and on reconstructed sagittal computed tomographic images in all patients. These results suggest that use of allograft is effective for treatment of upper cervical spine abnormalities in pediatric patients with Down syndrome.
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Mitchell A, Upasani VV, Bartley CE, Newton PO, Yaszay B. Rigid segmental cervical spine instrumentation is safe and efficacious in younger children. Childs Nerv Syst 2019; 35:985-990. [PMID: 30941509 DOI: 10.1007/s00381-019-04130-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The utilization of cervical spine instrumentation in the young pediatric patient is not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10. METHODS Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006, and March 31, 2015. Patients were ≤ 10 years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and postoperative follow-up data were collected. RESULTS Twenty children met the criteria and were included in the study with a mean follow-up of 10.6 months (3 months-2 years). Initial indication for cervical spine correction surgery included deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5-mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postoperative immobilization included 16 halo fixation, 3 collars, and 1 CTO. Overall, there were five complications related to the surgery. Two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5-mm segmental cervical spine instrumentation). One patient developed a postoperative infection that required incision and drainage. Five patients developed superficial pin infections for their halo. Two deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation. CONCLUSIONS Rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.
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Affiliation(s)
- Ana Mitchell
- University of California San Diego, San Diego, CA, USA
| | - Vidyadhar V Upasani
- University of California San Diego, San Diego, CA, USA
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Carrie E Bartley
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Peter O Newton
- University of California San Diego, San Diego, CA, USA
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Burt Yaszay
- University of California San Diego, San Diego, CA, USA.
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.
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Alalade AF, Ogando-Rivas E, Forbes J, Ottenhausen M, Uribe-Cardenas R, Hussain I, Nair P, Lehner K, Singh H, Kacker A, Anand VK, Hartl R, Baaj A, Schwartz TH, Greenfield JP. A Dual Approach for the Management of Complex Craniovertebral Junction Abnormalities: Endoscopic Endonasal Odontoidectomy and Posterior Decompression with Fusion. World Neurosurg X 2019; 2:100010. [PMID: 31218285 PMCID: PMC6580888 DOI: 10.1016/j.wnsx.2019.100010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction. METHODS Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery. RESULTS A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0. CONCLUSIONS The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.
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Affiliation(s)
- Andrew F. Alalade
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Elizabeth Ogando-Rivas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jonathan Forbes
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Malte Ottenhausen
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Rafael Uribe-Cardenas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Prakash Nair
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Kurt Lehner
- Zucker School of Medicine, Hofstra-Northwell Health School of Medicine, New York, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Vijay K. Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ali Baaj
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Theodore H. Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Alassaf N, Attia W. Treatment of chronic bilateral facet dislocation in a 6-year-old: A case report. SAGE Open Med Case Rep 2019; 6:2050313X18819615. [PMID: 30788109 PMCID: PMC6372996 DOI: 10.1177/2050313x18819615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 11/22/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives: Spine injuries seldom affect the subaxial spine in children less than 9 years of age. We describe the management of a chronic paediatric bilateral facet dislocation. Methods: Case report and literature review. A 6-year-old boy presented 10 weeks after a motor vehicle collision with bilateral C4–C5 malunited facet dislocation. He had an incomplete spinal cord injury; right brown sequard hemiplegia, Frankel grade D. Results: Surgical management was through posterior–anterior–posterior approach without preoperative skull traction. Two years postoperatively, the child was asymptomatic, ambulating and functioning well. The injury had healed in radiographs. Conclusion: A combined approach for chronic bilateral facet dislocation applies to the paediatric age group to realign the spine.
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Affiliation(s)
- Nabil Alassaf
- Department of Spine Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Walid Attia
- Department of Spine Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
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Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Evaluate radiographic and clinical outcomes for infants and children, who underwent rigid occipito-cervical fixation for traumatic craniocervical dissociation (tCCD). SUMMARY OF BACKGROUND DATA Traumatic craniocervical dissociation is devastating. Children are at high risk but make up a large number of survivors. Non-rigid fixation has traditionally been favored over screw and rod constructs due to inherent challenges involved with instrumenting the pediatric craniocervical junction. Therefore, outcomes for rigid occipito-cervical instrumentation in infants and young children with tCCD remain uncertain. METHODS Retrospective review of children who survived tCCD between 2006 and 2016 and underwent rigid occipito-cervical fixation. RESULTS Fifteen children, from 8 months to 8 years old (mean, 3.8 yr), were either a passenger (n = 11) or a pedestrian (n = 4) in a motor vehicle accident. Seven patients had weakness: five with quadriplegia, one with hemiparesis, and one with bilateral upper extremity paresis. Ten patients had concurrent C1-2 instability. At last follow-up, four patients had improved motor function: one with bilateral upper extremity paresis and one with hemiparesis regained full strength, one with quadriplegia regained function on one side while another regained function in bilateral upper extremities. All underwent rigid posterior occipito-cervical fixation, with two patients requiring additional anterior and posterior fixation at non-contiguous levels. Fourteen patients were stable on flexion-extension x-rays at a mean follow-up of 31 months (9-1 yr or longer, 7-2 yr or longer). There were no cases of deformity, growth disturbance, or subaxial instability. CONCLUSION Children who survive tCCD may regain function after stabilization. Rigid internal rod and screw fixation in infants and young children safely provided long-term stability. We advocate using C2 translaminar screws to exploit the favorable anatomy of pediatric lamina to minimize the risks of occipitocervical (OC) instrumentation. LEVEL OF EVIDENCE 4.
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Janjua MB, Hwang SW, Samdani AF, Pahys JM, Baaj AA, Härtl R, Greenfield JP. Instrumented arthrodesis for non-traumatic craniocervical instability in very young children. Childs Nerv Syst 2019; 35:97-106. [PMID: 29959504 DOI: 10.1007/s00381-018-3876-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022]
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.
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Affiliation(s)
- M Burhan Janjua
- Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA. .,Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA. .,Department of Orthopaedic and Neurological Surgery, University of Pennsylvania Hospital, Philadelphia, PA, USA.
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Ali A Baaj
- Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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Mendenhall S, Mobasser D, Relyea K, Jea A. Spinal instrumentation in infants, children, and adolescents: a review. J Neurosurg Pediatr 2019; 23:1-15. [PMID: 30611158 DOI: 10.3171/2018.10.peds18327] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/04/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVEThe evolution of pediatric spinal instrumentation has progressed in the last 70 years since the popularization of the Harrington rod showing the feasibility of placing spinal instrumentation into the pediatric spine. Although lacking in pediatric-specific spinal instrumentation, when possible, adult instrumentation techniques and tools have been adapted for the pediatric spine. A new generation of pediatric neurosurgeons with interest in complex spine disorder has pushed the field forward, while keeping the special nuances of the growing immature spine in mind. The authors sought to review their own experience with various types of spinal instrumentation in the pediatric spine and document the state of the art for pediatric spine surgery.METHODSThe authors retrospectively reviewed patients in their practice who underwent complex spine surgery. Patient demographics, operative data, and perioperative complications were recorded. At the same time, the authors surveyed the literature for spinal instrumentation techniques that have been utilized in the pediatric spine. The authors chronicle the past and present of pediatric spinal instrumentation, and speculate about its future.RESULTSThe medical records of the first 361 patients who underwent 384 procedures involving spinal instrumentation from July 1, 2007, to May 31, 2018, were analyzed. The mean age at surgery was 12 years and 6 months (range 3 months to 21 years and 4 months). The types of spinal instrumentation utilized included occipital screws (94 cases); C1 lateral mass screws (115 cases); C2 pars/translaminar screws (143 cases); subaxial cervical lateral mass screws (95 cases); thoracic and lumbar spine traditional-trajectory and cortical-trajectory pedicle screws (234 cases); thoracic and lumbar sublaminar, subtransverse, and subcostal polyester bands (65 cases); S1 pedicle screws (103 cases); and S2 alar-iliac/iliac screws (56 cases). Complications related to spinal instrumentation included hardware-related skin breakdown (1.8%), infection (1.8%), proximal junctional kyphosis (1.0%), pseudarthroses (1.0%), screw malpositioning (0.5%), CSF leak (0.5%), hardware failure (0.5%), graft migration (0.3%), nerve root injury (0.3%), and vertebral artery injury (0.3%).CONCLUSIONSPediatric neurosurgeons with an interest in complex spine disorders in children should develop a comprehensive armamentarium of safe techniques for placing rigid and nonrigid spinal instrumentation even in the smallest of children, with low complication rates. The authors' review provides some benchmarks and outcomes for comparison, and furnishes a historical perspective of the past and future of pediatric spine surgery.
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Affiliation(s)
- Stephen Mendenhall
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | - Dillon Mobasser
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | | | - Andrew Jea
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
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Improvise, adapt and overcome-challenges in management of pediatric congenital atlantoaxial dislocation. Clin Neurol Neurosurg 2018; 171:85-94. [DOI: 10.1016/j.clineuro.2018.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/18/2022]
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Brockmeyer DL, Sivakumar W, Mazur MD, Sayama CM, Goldstein HE, Lew SM, Hankinson TC, Anderson RCE, Jea A, Aldana PR, Proctor M, Hedequist D, Riva-Cambrin JK. Identifying Factors Predictive of Atlantoaxial Fusion Failure in Pediatric Patients: Lessons Learned From a Retrospective Pediatric Craniocervical Society Study. Spine (Phila Pa 1976) 2018; 43:754-760. [PMID: 29189644 DOI: 10.1097/brs.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study with multivariate analysis. OBJECTIVE To determine factors predictive of posterior atlantoaxial fusion failure in pediatric patients. SUMMARY OF BACKGROUND DATA Fusion rates for pediatric posterior atlantoaxial arthrodesis have been reported to be high in single-center studies; however, factors predictive of surgical non-union have not been identified by a multicenter study. METHODS Clinical and surgical details for all patients who underwent posterior atlantoaxial fusion at seven pediatric spine centers from 1995 to 2014 were retrospectively recorded. The primary outcome was surgical failure, defined as either instrumentation failure or fusion failure seen on either plain x-ray or computed tomography scan. Multiple logistic regression analysis was undertaken to identify clinical and technical factors predictive of surgical failure. RESULTS One hundred thirty-one patients met the inclusion criteria and were included in the analysis. Successful fusion was seen in 117 (89%) of the patients. Of the 14 (11%) patients with failed fusion, the cause was instrumentation failure in 3 patients (2%) and graft failure in 11 (8%). Multivariate analysis identified Down syndrome as the single factor predictive of fusion failure (odds ratio 14.6, 95% confidence interval [3.7-64.0]). CONCLUSION This retrospective analysis of a multicenter cohort demonstrates that although posterior pediatric atlantoaxial fusion success rates are generally high, Down syndrome is a risk factor that significantly predicts the possibility of surgical failure. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Walavan Sivakumar
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Marcus D Mazur
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Christina M Sayama
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR.,Neuro-Spine Program, Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Hannah E Goldstein
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
| | - Sean M Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Richard C E Anderson
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
| | - Andrew Jea
- Goodman Campbell Brain and Spine, Indianapolis, IN.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Philipp R Aldana
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Florida, Jacksonville, FL
| | - Mark Proctor
- Department of Pediatric Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay K Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Ito K, Imagama S, Ando K, Kobayashi K, Tsushima M, Matsumoto A, Morozumi M, Tanaka S, Machino M, Nishida Y, Ishiguro N. Posterior fusion of the occipital axis in children with upper cervical disorder using both C2 pedicle and laminar screws (C2 hybrid screws). Spine Surg Relat Res 2018; 2:82-85. [PMID: 31440652 PMCID: PMC6698545 DOI: 10.22603/ssrr.2017-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/07/2017] [Indexed: 12/05/2022] Open
Abstract
Introduction An occipital-cervical surgery for children is challenging for surgeons because of the immature bone quality, extensive anatomical variability, and small osseous structures. Furthermore, occipital-C2 fusion in children results in great stress on the C2 screws. We report a technique that uses both C2 pedicle and bilateral lateral mass screws (C2 hybrid screws) in children with an upper cervical disorder to preserve motion segment and secure strength in those who require occipital-cervical fusion. Case Report Case 1 was that of a 5-year-old girl with Down syndrome who had atlantoaxial dislocation and os odontoideum. Owing to the C1 hypoplasia, the posterior arch was fractured by the C1 lateral mass screw. Therefore, O-C2 fusion was performed. C2 bilateral lamina screws were added along with the C2 bilateral pedicle screws for reinforcement. Case 2 was that of an 8-year-old boy who presented with torticollis and neck pain. The patient was diagnosed as having atlantoaxial rotatory fixation. The right vertebral artery was obstructed, and the left vertebral artery was dominant. The C1 posterior arch was bifid and assimilated with the occipital bone. C2 bilateral lamina screws were added with the right C2 pedicle screw for reinforcement. Both cases attained bone union after O-C2 fusion surgery using hybrid screws. Conclusions The use of C2 hybrid screws with both C2 pedicle and bilateral lateral mass screws can preserve mobile segments in the fusion area in young children who require occipital-cervical fixation.
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Affiliation(s)
- Kenyu Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Mikito Tsushima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Akiyuki Matsumoto
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masayoshi Morozumi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Satoshi Tanaka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshihiro Nishida
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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Watanabe K, Hirano T, Katsumi K, Ohashi M, Shoji H, Hasegawa K, Ito T, Endo N. Radiographic Outcomes of Upper Cervical Fusion for Pediatric Patients Younger Than 10 Years. Spine Surg Relat Res 2017; 1:14-19. [PMID: 31440607 PMCID: PMC6698536 DOI: 10.22603/ssrr.1.2016-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 12/06/2016] [Indexed: 12/29/2022] Open
Abstract
Purpose: This study aimed to investigate radiographic outcomes after posterior spinal fusion (PSF) for pediatric patients younger than 10 years with upper cervical disorders. Methods: Thirteen patients (mean age at surgery, 5.9 years; range, 1 to 9 years) who underwent PSF with a minimum of 2 years of follow-up (mean, 5.8 years) were included. Diagnoses were atlanto-axial instability due to congenital disorders for 11 patients and atlanto-axial rotatory fixation for 2 patients. The fusion area was occipito-cervical for 7 patients and C1/2 for 6 patients. PSF was performed using rigid screw-rod constructs for 6 patients and conventional techniques for 7 patients. Ten patients required halo immobilization after surgery. Fusion status, perioperative complications, radiographic alignment, and range of motion (ROM) from C2 to C7 were evaluated. Results: Twelve patients successfully achieved bony fusion (fusion rate, 92%), but complications occurred in 5 patients. Regarding radiographic measures (preoperative/postoperative/final follow-up), the mean atlanto-dental interval was significantly reduced (8.0 mm/2.7 mm/3.5 mm) and the C2-7 ROM was increased (from 49.4 degrees to 66.0 degrees) at the final follow-up (both comparisons, p<0.05). Sagittal alignment was unchanged. Conclusion: Use of rigid screw-rod instrumentation in the upper cervical spine with careful radiological evaluation is amenable for pediatric patients younger than 10 years. However, conventional procedures such as wiring fixation with rigid external immobilization are still alternative options for preventing serious neurological and vascular complications.
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Affiliation(s)
- Kei Watanabe
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
| | - Toru Hirano
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
| | - Keiichi Katsumi
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
| | - Masayuki Ohashi
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
| | - Hirokazu Shoji
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
| | | | - Takui Ito
- Department of Orthopedic Surgery, Niigata City General Hospital, Japan
| | - Naoto Endo
- Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Japan
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Rigid Occipitocervical Instrumented Fusion for Atlantoaxial Instability in an 18-Month-Old Toddler With Brachytelephalangic Chondrodysplasia Punctata: A Case Report. Spine (Phila Pa 1976) 2017; 42:E1380-E1385. [PMID: 28338574 DOI: 10.1097/brs.0000000000002170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE We report here on an 18-month-old boy with brachytelephalangic chondrodysplasia punctata (BCDP), whose atlantoaxial instability was successfully managed with occipitocervical instrumented fusion (OCF) using screw and rod instrumentations. SUMMARY OF BACKGROUND DATA Recently, there have been a number of reports on BCDP with early onset of cervical myelopathy. Surgical OCF is a vital intervention to salvage affected individuals from the life-threatening morbidity. Despite recent advancement of instrumentation techniques, however, rigid OCF is technically demanding in very young children with small and fragile osseous elements. To our best knowledge, this is the first report on application of the instrumentation technique to a toddler patient with BCDP. METHODS A 16-month-old boy with BCDP presented with tetraplegia and swallow obstacle. Hypoplasia of the odontoid process and atlantoaxial instability were present in lateral radiographs. T2-weighted magnetic resonance (MR) images revealed a high signal region in the spinal cord at the C1-2 and C7-T1 levels. Cervical computed tomography (CT) showed that the pedicles and lateral masses in the cervical spine were small and immature, but the laminae were comparatively thick. RESULTS One week before surgery, the patient was fitted with a Halo-body jacket. We performed plate-rod placement with occipital cortical screws and C2/C3 interlaminar screws, and added an autogenous bone graft using the right 8 and 9 ribs. Rigid fixation of the occipito-cervical spine was completed successfully without major complications. Postoperative halo-body jacket immobilization was continued for 3 months, after which Aspen collar was fitted. CT confirmed occipitocervical bone fusion at 6 months after surgery. Mild clinical improvements in motor power of the affected muscles and swallowing were witnessed at 1 year postoperatively. CONCLUSION Rigid fixation using screw, rod, and occipital plate instrumentation was successful in an 18-month-old toddler with BCDP and atlantoaxial instability. Bone fusion was achieved at postoperative 6 months. LEVEL OF EVIDENCE 5.
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Zhang YH, Shao J, Chou D, Wu JF, Song J, Zhang J. C1-C2 Pedicle Screw Fixation for Atlantoaxial Dislocation in Pediatric Patients Younger than 5 Years: A Case Series of 15 Patients. World Neurosurg 2017; 108:498-505. [DOI: 10.1016/j.wneu.2017.09.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/08/2017] [Accepted: 09/09/2017] [Indexed: 10/18/2022]
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Abstract
PURPOSE To report indications, outcomes and complications of instrumented cervical spinal fusion in a consecutive series of children at major university hospitals. METHODS A retrospective, single surgeon series identified 35 consecutive children with a mean follow-up (FU) of 2.5 years undergoing instrumented cervical spinal fusion between 2005 and 2015. RESULTS The main indications were skeletal dysplasia and trauma associated cervical instability. Surgical complications were observed in 12 (34%) patients with multiple complications in four (11%). Four (11%) children required at least one revision surgery, three for nonunion and one for graft dislodgement. All were fused at FU. Surgical complications were more common in children undergoing occipitocervical (OC) fusion than in those avoiding fusion of the OC junction (60% versus 24%) (p = 0.043). Complications were found significantly more in children operated on under the age of ten years than above (50% versus 18%) (p = 0.004). The risk of complications was not dependent on the indications for surgery (skeletal dysplasia versus trauma) (p = 0.177). CONCLUSION Skeletal dysplasia associated cervical instability and cervical spine injuries represented the most common indications for instrumented cervical spinal fusion in children. Complications were observed in one-third of these children and 11% required revision surgery for complications. OC spinal fusion and spinal fusion before the age of ten years are associated with higher risk of surgical complications and increased mortality than non-OC fusions and cervical spinal fusions at an older age. We urge surgeons to employ caution to the patient, timing and procedure selection when treating paediatric cervical spine.
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Affiliation(s)
- M. Lastikka
- Department of Paediatric Orthopaedic Surgery and Department of Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland,Correspondence should be sent to M. Lastikka MD, Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland. E-mail:
| | - J. Aarnio
- Medical Faculty, University of Turku, Finland
| | - I. Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
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Özbek Z, Özkara E, Vural M, Arslantaş A. Treatment of cervical subaxial injury in the very young child. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1193-1198. [PMID: 29086032 DOI: 10.1007/s00586-017-5316-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/31/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Infant's cervical spine has serious differences compared to other pediatric age groups and adults. Anatomical and biomechanical constitution of an infant is unique, and the pediatric spine gradually begins to resemble the structure of the adult spine after age 10. In addition, clinical presentation of the cervical spinal traumas has many distinctions from birth to the end of adolescence. In young children, cervical spine traumas are mainly localized in the upper cervical region. Trauma localized in subaxial cervical region and fracture-dislocations are rare in infants. CASE REPORT Here, we present a case history of a 7-month-old infant with surgically treated severe subaxial flexion-distraction injury. Neurologic examination revealed complete loss of motor function below C5. A whole-body CT was taken and we observed that C5-6 dislocated anteriorly approximately one vertebra size and also unilateral facet joint was locked. The patient was intubated and closed reduction was attempted with fluoroscopy under general anesthesia, but it was unsuccessful. Whereupon C5-6 microdiscectomy was performed with the anterior approach and fixation was provided with the craniofacial miniplate. Despite anterior stabilization, exact posterior alignment could not been achieved so, posterior approach was added to the surgery. At 12 month follow-up, the patient improved from quadriparesis to paraparesis and we achieved a satisfactory radiological outcome.
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Affiliation(s)
- Zühtü Özbek
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey.
| | - Emre Özkara
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
| | - Murat Vural
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
| | - Ali Arslantaş
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
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Abstract
The craniovertebral junction (CVJ) has attracted more attention in pediatric medicine in recent years due to the progress in surgical technologies allowing a direct approach to the CVJ in children. The CVJ is the site of numerous pathologies, most originating in bone anomalies resulting from abnormal CVJ development. Before discussing the surgical approaches to CVJ, three points should be borne in mind: first, that developmental anatomy demonstrates age-dependent mechanisms and the pathophysiology of pediatric CVJ anomalies; second, that CT-based dynamic simulations have improved our knowledge of functional anatomy, enabling us to locate CVJ lesions with greater certainty; and third, understanding the complex structure of the pediatric CVJ also clarifies the surgical anatomy. This review begins with a description of the embryonic developmental process of the CVJ, comprising ossification and resegmentation of the somite. From the clinical perspective, pediatric CVJ lesions can be divided into three categories: developmental bony anomalies with or without instability, stenotic CVJ lesions, and others. After discussing surgery and management based on this classification, the author describes surgical outcomes on his hands, and finally proceeds to address controversial issues specific for pediatric CVJ surgery. The lessons, which the author has gleaned from his experience in pediatric CVJ surgery, are also presented briefly in this review. Recent technological progress has facilitated pediatric surgery of the CVJ. However, it is important to recognize that we are still far from reliably and consistently obtaining satisfactory results. Further progress in this area awaits contributions of the coming generations of pediatric surgeons.
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Affiliation(s)
- Nobuhito MOROTA
- Division of Neurosurgery, Tokyo Metropolitan Children’s Medical Center, Fuchu, Tokyo, Japan
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Zhang YH, Shen L, Shao J, Chou D, Song J, Zhang J. Structural Allograft versus Autograft for Instrumented Atlantoaxial Fusions in Pediatric Patients: Radiologic and Clinical Outcomes in Series of 32 Patients. World Neurosurg 2017. [PMID: 28624564 DOI: 10.1016/j.wneu.2017.06.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Allograft with wire techniques showed a low fusion rate in pediatric atlantoaxial fusions (AAFs) in early studies. Using allograft in pediatric AAFs with screw/rod constructs has not been reported. Thus we compared the fusion rate and clinical outcomes in pediatric patients who underwent AAFs with screw/rod constructs using either a structural autograft or allograft. METHODS Pediatric patients (aged ≤12 years) who underwent AAFs between 2007 and 2015 were retrospectively evaluated. Patients were divided into 2 groups (allograft or autograft). Clinical and radiographic results were collected from hospital records and compared. RESULTS A total of 32 patients were included (18 allograft, 14 autograft). There were no significant group differences in age, sex, weight, diagnosis, or duration of follow-up. A similar fusion rate was achieved (allograft: 94%, 17/18; autograft: 100%, 14/14); however, the average fusion time was 3 months longer in the allograft group. Blood loss was significantly lower in the allograft group (68 ± 8.5 mL) than the autograft group (116 ± 12.5 mL). Operating time and length of hospitalization were slightly (nonsignificantly) shorter for the allograft group. A significantly higher overall incidence of surgery-related complications was seen in the autograft group, including a 16.7% (2/14) rate of donor-site-related complications. CONCLUSIONS The use of allograft for AAF was safe and efficacious when combined with rigid screw/rod constructs in pediatric patients, with a similar fusion rate to autografts and an acceptable complication rate. Furthermore, blood loss was less when using allograft and donor-site morbidity was eliminated; however, the fusion time was increased.
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Affiliation(s)
- Yue-Hui Zhang
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Shen
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Shao
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Jia Song
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Zhang
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Yasmeh S, Quinn A, Harris L, Sanders AE, Sousa T, Skaggs DL, Andras LM. Periosteal turndown flap for posterior occipitocervical fusion: a technique review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2303-2307. [PMID: 28466094 DOI: 10.1007/s00586-017-5085-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 03/20/2017] [Accepted: 04/01/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE Recently, several authors have proposed techniques for improving the fusion rate in pediatric posterior occipitocervical fusion including a variety of implants and the use of bone morphogenetic protein. A technique by Koop et al. using a periosteal flap for occipitocervical arthrodesis was described in 1984. METHODS A straight incision is made about the posterior neck to expose the occipitocervical region from the inion superiorly to the lowest cervical vertebrae to be fused inferiorly. The occiput is exposed superficial to the periosteum, which is then reflected and elevated from the occiput. The attachment is preserved at the caudal base of the flap and reflected over the intended area of fusion. When possible, fixation is then performed with cables, wires, screws, hooks, or plates. CASE EXAMPLE A 6-year-old male with an occiput to C2 distraction injury underwent posterior spinal fusion from occiput to C3 using sublaminar wires, periosteal turndown flap, and autologous iliac crest bone graft. CONCLUSION In small children with traumatic upper cervical spine instability, the periosteal turndown technique may be used as a safe adjunct for occipitocervical fusions.
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Affiliation(s)
- Siamak Yasmeh
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Adrienne Quinn
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Liam Harris
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - Austin E Sanders
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - Ted Sousa
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - David L Skaggs
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.
| | - Lindsay M Andras
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
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