Craniovertebral junction fixation in children less than 5 years

• Published in: European spine journal Vol. 29; no. 5; pp. 961 - 969
• Main Authors: Grover, Patrick J., Harris, Lauren S., Thompson, Dominic N. P.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.05.2020; Springer Nature B.V
• Subjects: Atlanto-Axial Joint - diagnostic imaging; Atlanto-Axial Joint - surgery; Autografts; Bone grafts; Bone Plates; Bone surgery; Cervical Vertebrae - diagnostic imaging; Cervical Vertebrae - surgery; Child, Preschool; Children; Humans; Immobilization; Infant; Joint Instability - surgery; Medicine; Medicine & Public Health; Morbidity; Neurosurgery; Original Article; Radiography; Reoperation; Retrospective Studies; Skin & tissue grafts; Spinal Fusion; Spine (cervical); Surgery; Surgical Orthopedics; Trauma; Treatment Outcome; Tumors; Semi-rigid fixation; Spine; Craniovertebral; Paediatrics
• ISSN: 0940-6719; 1432-0932
• DOI: 10.1007/s00586-020-06313-x

Purpose Whilst rigid fixation for craniovertebral instability is the gold standard, in very young, small children conventional management may have to be modified. We present a single-centre experience of craniocervical fixation in children under 5 years. Methods A retrospective review of cases that had undergone atlantoaxial (AA) or occipitocervical (OC) fixation aged under 5 years. Fusion was assessed using computerised tomography or flexion extension X-rays. Results Twenty-six children (median age 2.3, range 0.8–4.9 years, 19 under the age of 3) underwent OC ( n  = 19) or AA ( n  = 7) fusion between 1999 and 2016. Pathology comprised 17 congenital, five trauma, two tumour and two post-infection cases. Twenty-one patients underwent sublaminar cable fixation with calvarial, autologous bone graft and halo-body orthosis immobilisation. An occipital plate and rods to sublaminar wire construct were used in four cases. A rigid instrumented fixation with occipital plate and C2 pedicle screws was utilised in one case. Follow-up was for a median of 2.8 years (range 0.03–16.3 years). Initial fusion rate was 91%, reaching 100% following two re-operations. Ninety-two per cent of patients were neurologically stable or improved following surgery. Twenty-one patients had a good overall outcome. Two patients had post-operative neurological deteriorations, and four died due to non-procedure related causes. Pin site morbidity secondary to halo use occurred in five cases. Conclusion High fusion rates with good outcomes are achievable using semi-rigid fixation in the under 5-year-olds. Full thickness, autologous calvarial bone graft secured with wire cables and halo external orthosis offers a safe and effective alternative technique when traditional screw instrumentation is not feasible. Graphic abstract These slides can be retrieved under Electronic Supplementary Material.