Growth and alignment of the pediatric subaxial cervical spine following rigid instrumentation and fusion: a multicenter study of the Pediatric Craniocervical Society

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OBJECTIVE

The long-term effects of surgical fusion on the growing subaxial cervical spine are largely unknown. Recent cross-sectional studies have demonstrated that there is continued growth of the cervical spine through the teenage years. The purpose of this multicenter study was to determine the effects of rigid instrumentation and fusion on the growing subaxial cervical spine by investigating vertical growth, cervical alignment, cervical curvature, and adjacent-segment instability over time.

METHODS

A total of 15 centers participated in this multi-institutional retrospective study. Cases involving children less than 16 years of age who underwent rigid instrumentation and fusion of the subaxial cervical spine (C-2 and T-1 inclusive) with at least 1 year of clinical and radiographic follow-up were investigated. Charts were reviewed for clinical data. Postoperative and most recent radiographs, CT, and MR images were used to measure vertical growth and assess alignment and stability.

RESULTS

Eighty-one patients were included in the study, with a mean follow-up of 33 months. Ninety-five percent of patients had complete clinical resolution or significant improvement in symptoms. Postoperative cervical kyphosis was seen in only 4 patients (5%), and none developed a swan-neck deformity, unintended adjacent-level fusion, or instability. Of patients with at least 2 years of follow-up, 62% demonstrated growth across the fusion construct. On average, vertical growth was 79% (4-level constructs), 83% (3-level constructs), or 100% (2-level constructs) of expected growth. When comparing the group with continued vertical growth to the one without growth, there were no statistically significant differences in terms of age, sex, underlying etiology, surgical approach, or number of levels fused.

CONCLUSIONS

Continued vertical growth of the subaxial spine occurs in nearly two-thirds of children after rigid instrumentation and fusion of the subaxial spine. Failure of continued vertical growth is not associated with the patient’s age, sex, underlying etiology, number of levels fused, or surgical approach. Further studies are needed to understand this dichotomy and determine the long-term biomechanical effects of surgery on the growing pediatric cervical spine.

Article Information

Correspondence Hannah E. Goldstein: The Neurological Institute, New York, NY. heg2117@columbia.edu.

INCLUDE WHEN CITING Published online April 20, 2018; DOI: 10.3171/2018.1.PEDS17551.

Disclosures Dr. Limbrick reports receipt of support from Medtronic and Microbot Medical, Inc., for non–study-related clinical or research effort. Dr. Pahys reports a consultant relationship with DePuy Synthes, Zimmer Biomet, and Globus Medical.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Alignment classification. Drawing depicting the classification of cervical spine alignment into 4 groups based on the direction and extent of displacement of the vertebral bodies from a line drawn between the posterior border of C-2 and C-7. Lordosis (A) has anterior displacement greater than 2 mm, straight alignment (B) has anterior or posterior displacement within 2 mm, kyphosis (C) has posterior displacement greater than 2 mm, and swan-neck deformity (D) has simultaneous anterior and posterior displacement greater than 2 mm. Modified from Toyama et al.: Realignment of postoperative cervical kyphosis in children by vertebral remodeling. Spine (Phila Pa 1976) 19(22):2565–2570, 1994, https://journals.lww.com/spinejournal/toc/1994/11001.

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    A: Measurement of the entire subaxial spine from the midsagittal inferior endplate of C-2 to the midsagittal inferior endplate of C-7. B: Measurement of the fused construct from the midsagittal superior endplate of the most rostral level of the fusion construct to the midsagittal inferior endplate of the caudal-most level of the construct. Figure is available in color online only.

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    A and B: Immediate postoperative (A) and 45-month follow-up (B) upright lateral radiographs obtained in a female patient who underwent C4–6 posterior instrumentation and fusion at the age of 9 years. The radiograph obtained 45 months after surgery shows 40% growth across the fusion construct. C and D: Immediate postoperative (C) and 83-month follow-up (D) upright lateral radiographs obtained in a female patient who underwent C4–6 posterior instrumentation and fusion at the age of 13 years. The radiograph obtained 83 months after surgery demonstrates no growth across the fusion construct (measurement indicated by blue lines). Figure is available in color online only.

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    Growth across the fusion construct in patients with continued growth and at least 2 years of follow-up after a 2-level fusion compared to expected growth across 2 levels of the normal pediatric subaxial spine. The slopes of the lines represent the rate of growth. Figure is available in color online only.

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    Growth across the fusion construct in patients with continued growth and at least 2 years of follow-up after a 3-level fusion compared to expected growth across 3 levels of the normal pediatric subaxial spine. The slopes of the lines represent the rate of growth. Figure is available in color online only.

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    Growth across the fusion construct in patients with continued growth and at least 2 years of follow-up after a 4-level fusion compared to expected growth across 4 levels of the normal pediatric subaxial spine. The slopes of the lines represent the rate of growth. Figure is available in color online only.

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    Growth across the fusion construct in patients with continued growth and at least 2 years of follow-up comparing anterior only, posterior only, and combined anterior/posterior approaches for a 3-level fusion. Figure is available in color online only.

References

  • 1

    Ahmed RTraynelis VCMenezes AH: Fusions at the craniovertebral junction. Childs Nerv Syst 24:120912242008

  • 2

    Anderson RCKan PGluf WMBrockmeyer DL: Long-term maintenance of cervical alignment after occipitocervical and atlantoaxial screw fixation in young children. J Neurosurg 105 (1 Suppl):55612006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bailey DK: The normal cervical spine in infants and children. Radiology 59:7127191952

  • 4

    Baker DHBerdon WE: Special trauma problems in children. Radiol Clin North Am 4:2893051966

  • 5

    Braakman RPenning L: The hyperflexion sprain of the cervical spine. Radiol Clin Biol 37:3093201968

  • 6

    Brockmeyer DApfelbaum RTippets RWalker MCarey L: Pediatric cervical spine instrumentation using screw fixation. Pediatr Neurosurg 22:1471571995

  • 7

    Brockmeyer DL: Advanced surgery for the subaxial cervical spine in children in Brockmeyer DL (ed): Advanced Pediatric Craniocervical Surgery. New York: Thieme2006 pp 109122

    • Search Google Scholar
    • Export Citation
  • 8

    Fearon JAMunro IRBruce DA: Observations on the use of rigid fixation for craniofacial deformities in infants and young children. Plast Reconstr Surg 95:6346381995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Fesmire FMLuten RC: The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med 7:1331421989

  • 10

    Garber STBrockmeyer DL: Management of subaxial cervical instability in very young or small-for-age children using a static single-screw anterior cervical plate: indications, results, and long-term follow-up. J Neurosurg Spine 24:8928962016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Goldberg GAlbert TJVaccaro ARHilibrand ASAnderson DGWharton N: Short-term comparison of cervical fusion with static and dynamic plating using computerized motion analysis. Spine (Phila Pa 1976) 32:E371E3752007

    • Search Google Scholar
    • Export Citation
  • 12

    Goldstein JAPosnick JCWells MDSlate RKThorner PS: An assessment of postnatal growth after in utero long bone osteotomy with fixation. Plast Reconstr Surg 94:1601661994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Greaves LLVan Toen CMelnyk AKoenig LZhu QTredwell S: Pediatric and adult three-dimensional cervical spine kinematics: effect of age and sex through overall motion. Spine (Phila Pa 1976) 34:165016572009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Johnson KTAl-Holou WNAnderson RCWilson TJKarnati TIbrahim M: Morphometric analysis of the developing pediatric cervical spine. J Neurosurg Pediatr 18:3773892016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Kale SSAilawadhi PYerramneni VKChandra PSKumar RSharma BS: Pediatric bony craniovertebral junction abnormalities: Institutional experience of 10 years. J Pediatr Neurosci 6 (Suppl 1):S91S952011

    • Search Google Scholar
    • Export Citation
  • 16

    Kalfas IWilberger JGoldberg AProstko ER: Magnetic resonance imaging in acute spinal cord trauma. Neurosurgery 23:2952991988

  • 17

    Kennedy BCD’Amico RSYoungerman BEMcDowell MMHooten KGCouture D: Long-term growth and alignment after occipitocervical and atlantoaxial fusion with rigid internal fixation in young children. J Neurosurg Pediatr 17:941022016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Kennedy BCGoldstein HEAnderson RCEBrockmeyer DL: Surgery of the pediatric subaxial cervical spine in Winn HR (ed): Youmans & Winn Neurological Surgeryed 7. Philadelphia: Elsevier2016

    • Search Google Scholar
    • Export Citation
  • 19

    Kovács AFSauer SNStefenelli UKlein C: Growth of the orbit after frontoorbital advancement using nonrigid suture vs rigid plate fixation technique. J Pediatr Surg 43:207520812008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Martinez-Del-Campo ETurner JDSoriano-Baron HNewcomb AGKalb STheodore N: Pediatric occipitocervical fusion: long-term radiographic changes in curvature, growth, and alignment. J Neurosurg Pediatr 18:6446522016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Menezes AH: Craniocervical fusions in children. J Neurosurg Pediatr 9:5735852012

  • 22

    Pang DSun PP: Pediatric vertebral column and spinal cord injuries in Winn HR (ed): Youmans Neurological Surgeryed 5. Philadelphia: Saunders2004Vol 3 pp 35153557

    • Search Google Scholar
    • Export Citation
  • 23

    Papin PLabelle HDelorme SAubin CEde Guise JADansereau J: Long-term three-dimensional changes of the spine after posterior spinal instrumentation and fusion in adolescent idiopathic scoliosis. Eur Spine J 8:16211999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Townsend EH JrRowe ML: Mobility of the upper cervical spine in health and disease. Pediatrics 10:5675741952

  • 25

    Toyama YMatsumoto MChiba KAsazuma TSuzuki NFujimura Y: Realignment of postoperative cervical kyphosis in children by vertebral remodeling. Spine (Phila Pa 1976) 19:256525701994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Vitale MGMatsumoto HBye MRGomez JABooker WAHyman JE: A retrospective cohort study of pulmonary function, radiographic measures, and quality of life in children with congenital scoliosis: an evaluation of patient outcomes after early spinal fusion. Spine (Phila Pa 1976) 33:124212492008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    White AA IIIJohnson RMPanjabi MMSouthwick WO: Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res (109):85961975

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    White AA IIIPanjabi MM: Clinical Biomechanics of the Spine. Philadelphia: Lippincott1990

  • 29

    Yerramneni VKChandra PSKale SSLythalling RKMahapatra AK: A 6-year experience of 100 cases of pediatric bony craniovertebral junction abnormalities: treatment and outcomes. Pediatr Neurosurg 47:45502011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Yuan NFraire JAMargetis MMSkaggs DLTolo VTKeens TG: The effect of scoliosis surgery on lung function in the immediate postoperative period. Spine (Phila Pa 1976) 30:218221852005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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