Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions

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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.

ABBREVIATIONS AP = anterior-posterior; BMP = bone morphogenetic protein; EBL = estimated blood loss; EMG = electromyography; IONM = intraoperative neurophysiological monitoring; IQR = interquartile range; LE = lower extremity; LM = lateral mass; NF1 = neurofibromatosis type 1; POD = postoperative day; ROM = range of motion; SAC = space available for spinal cord; SCC = spinal cord compression; SSEP = somatosensory evoked potential; tcMEP = transcranial motor evoked potential; UE = upper extremity; VA = vertebral artery.
Article Information

Contributor Notes

Correspondence Daniel J. Hedequist: Boston Children’s Hospital, Boston, MA. daniel.hedequist@childrens.harvard.edu.INCLUDE WHEN CITING Published online August 16, 2019; DOI: 10.3171/2019.5.PEDS19200.Disclosures Michael P. Glotzbecker: Biomet, DePuy (a Johnson & Johnson Company), Medtronic, and NuVasive—paid presenter or speaker; member of CSSG, GSSG, and HSG—research support; Orthobullets—publishing royalties, financial or material support. Michael T. Hresko: American College of Rheumatology Arthritis Foundation, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society—board or committee member; Arthritis and Rheumatism and New England Journal of Medicine—editorial or governing board; EOSI and Johnson & Johnson—stock or stock options. Lawrence I. Karlin: K2M—paid for housing and transportation for research meeting, other financial or material support. John B. Emans: Zimmer/Biomet, Medtronic Sofamor Danek, and Synthes—paid consultant; DePuy (a Johnson & Johnson Company)—IP royalties for VEPTR II; Journal of Children’s Orthopedics—editorial or governing board. Mark R. Proctor: Neurosurgery—editorial or governing board; spouse has stock options in and works for Vertex Pharmaceuticals in the field of cystic fibrosis.
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