Selection of a rigid internal fixation construct for stabilization at the craniovertebral junction in pediatric patients

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Object

Atlantoaxial and occipitocervical instability in children have traditionally been treated with posterior bone and wire fusion and external halo orthoses. Recently, successful outcomes have been achieved using rigid internal fixation, particularly C1–2 transarticular screws. The authors describe flow diagrams created to help clinicians determine which method of internal fixation to use in complex anatomical circumstances when bilateral transarticular screw placement is not possible.

Methods

The records of children who underwent either atlantoaxial or occipitocervical fixation with rigid internal fixation over an 11-year period were retrospectively reviewed to define flow diagrams used to determine treatment protocols.

Results

Among the 95 patients identified who underwent atlantoaxial or occipitocervical fixation, the craniocervical anatomy in 25 patients (six atlantoaxial and 19 occipitocervical fixations [26%]) required alternative methods of internal fixation. Types of screw fixation included loop or rod constructs anchored by combinations of C1–2 transarticular screws (15 constructs), C-1 lateral mass screws (11), C-2 pars screws (24), C-2 translaminar screws (one), and subaxial lateral mass screws (six). The mean age of the patients (15 boys and 10 girls) was 9.8 years (range 1.3–17 years). All 22 patients with greater than 3-month follow-up duration achieved solid bone fusion and maintained stable constructs on radiographic studies. Clinical improvement was seen in all patients who had preoperative symptoms.

Conclusions

Novel flow diagrams are suggested to help guide selection of rigid internal fixation constructs when performing pediatric C1–2 and occipitocervical stabilizations. Use of these flow diagrams has led to successful fusion in 25 pediatric patients with difficult anatomy requiring less common constructs.

Abbreviations used in this paper:CT = computed tomography; VA = vertebral artery.

Article Information

Address reprint requests to: Richard C. E. Anderson, M.D., The Neurological Institute, Room 210, 710 West 168th Street, New York, New York 10032. email: rca24@columbia.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Treatment flow diagram describing selection of rigid internal fixation constructs in pediatric patients with occipitocervical instability.

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    Treatment flow diagram describing selection of rigid internal fixation constructs in pediatric patients with C1–2 instability.

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    Case 3. Flexion (A) and extension (B) cervical spine x-ray films exhibiting os odontoideum with 8 mm of motion at C1–2. Preoperative cervical spine CT sagittal reconstructions showing an os odontoideum (C), as well as favorable (D) and unfavorable (E) C1–2 transarticular screw trajectories (arrows). Postoperative cervical spine x-ray film (F) showing a rigid atlantoaxial fixation construct in the form of a left C1–2 transarticular screw and a right Harms construct (C-1 lateral mass screw and C-2 pars screw connected by a rod).

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    Case 4. A and B: Flexion and extension cervical spine x-ray films showing C1–2 instability. C: Postoperative cervical spine x-ray film showing a rigid atlantoaxial fixation construct in the form of bilateral C-1 lateral mass screws, a right C-2 pars screw, and a left C-2 laminar screw with bilateral connecting rods. D: Postoperative axial CT scan demonstrating the C-2 laminar screw.

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    Case 12. A and B: Preoperative cervical spine CT scans with reconstruction. A: Sagittal view showing multilevel congenitally fused vertebral bodies from C-3 to C-6, which are typical of Klippel–Feil syndrome. B: Coronal view depicting occipitalization of the axis. C and D: Postoperative cervical spine x-ray films. C: Lateral view showing a custom U-loop secured with a left C1–2 transarticular screw and a right C-1 lateral mass screw. D: Anteroposterior view of craniocervical fixation construct.

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    Case 15. Lateral cervical spine x-ray film (A) showing swan neck deformity. Preoperative CT scan of the cervical spine with sagittal (B) and coronal (C) reconstructions exhibiting midline osseous hypoplasia from C-1 to C-3. Postoperative lateral cervical spine x-ray film (D) showing bilateral occipital screws, C-4 and C-5 lateral mass screws, and connecting rods.

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