Craniocervical fusions in children

Menezes, Arnold H.

doi:10.3171/2012.2.peds11371

Cited by 75 publications

(64 citation statements)

References 39 publications

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“…8 Menezes reviewed 850 craniovertebral fusions, and reported 98% success with bone fusion alone, and 100% success using rigid instrumentation. 17 In a recent analysis of outcomes of instrumented fusions in the pediatric cervical spine, occipitocervical fusions had a 99% fusion rate in 285 patients. 11 In our 4 cases, we have a 100% fusion rate to date.…”

Section: Discussionmentioning

confidence: 99%

Occipital condyle to cervical spine fixation in the pediatric population

Kosnik-Infinger

Glazier

Frankel

2014

PED

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Fixation at the craniovertebral junction (CVJ) is necessary in a variety of pediatric clinical scenarios. Traditionally an occipital bone to cervical fusion is preformed, which requires a large amount of hardware to be placed on the occiput of a child. If a patient has previously undergone a posterior fossa decompression or requires a decompression at the time of the fusion procedure, it can be difficult to anchor a plate to the occipital bone. The authors propose a technique that can be used when faced with this difficult challenge by using the occipital condyle as a point of fixation for the construct. Adult cadaveric and a limited number of case studies have been published using occipital condyle (C-0) fixation. This work was adapted for the pediatric population. Between 2009 and 2012, 4 children underwent occipital condyle to axial or subaxial spine fixation. One patient had previously undergone posterior fossa surgery for tumor resection, and 1 required decompression at the time of operation. Two patients underwent preoperative deformity reduction using traction. One child had a Chiari malformation Type I. Each procedure was performed using polyaxial screw-rod constructs with intraoperative neuronavigation supplemented by a custom navigational drill guide. Smooth-shanked 3.5-mm polyaxial screws, ranging in length from 26 to 32 mm, were placed into the occipital condyles. All patients successfully underwent occipital condyle to cervical spine fixation. In 3 patients the construct extended from C-0 to C-2, and in 1 from C-0 to T-2. Patients with preoperative halo stabilization were placed in a cervical collar postoperatively. There were no new postoperative neurological deficits or vascular injuries. Each patient underwent postoperative CT, demonstrating excellent screw placement and evidence of solid fusion. Occipital condyle fixation is an effective option in pediatric patients requiring occipitocervical fusion for treatment of deformity and/or instability at the CVJ. The use of intraoperative neuronavigation allows for safe placement of screws into C-0, especially when faced with a challenging patient in whom fixation to the occipital bone is not possible or is less than ideal.

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Section: Discussionmentioning

confidence: 99%

Occipital condyle to cervical spine fixation in the pediatric population

Kosnik-Infinger

Glazier

Frankel

2014

PED

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“…39,44,59,104 Distraction may be conducted using instrumentation between the occipital bone plate/screws and C1-2 vertebral instrumentation or with distraction between C-1 and C-2 when C-1 is congenitally fused with the occiput (atlas assimilation or occipitalization of the atlas) to increase the distance between the clivus and odontoid, allowing reduction and/or reducing dislocation. 39,44,59,104 Others have used titanium spacers and bone graft to distract between the joints of C-1 and C-2 to treat basilar invagination. 29 Purely intraoperative posterior distraction techniques can be effective for reduction of mild and moderate cases of basilar invagination.…”

Section: Distraction Reductionmentioning

confidence: 99%

Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update

Dlouhy

Dahdaleh

Menezes³

et al. 2015

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The craniovertebral junction (CVJ), or the craniocervical junction (CCJ) as it is otherwise known, houses the crossroads of the CNS and is composed of the occipital bone that surrounds the foramen magnum, the atlas vertebrae, the axis vertebrae, and their associated ligaments and musculature. The musculoskeletal organization of the CVJ is unique and complex, resulting in a wide range of congenital, developmental, and acquired pathology. The refinements of the transoral approach to the CVJ by the senior author (A.H.M.) in the late 1970s revolutionized the treatment of CVJ pathology. At the same time, a physiological approach to CVJ management was adopted at the University of Iowa Hospitals and Clinics in 1977 based on the stability and motion dynamics of the CVJ and the site of encroachment, incorporating the transoral approach for irreducible ventral CVJ pathology. Since then, approaches and techniques to treat ventral CVJ lesions have evolved. In the last 40 years at University of Iowa Hospitals and Clinics, multiple approaches to the CVJ have evolved and a better understanding of CVJ pathology has been established. In addition, new reduction strategies that have diminished the need to perform ventral decompressive approaches have been developed and implemented. In this era of surgical subspecialization, to properly treat complex CVJ pathology, the CVJ specialist must be trained in skull base transoral and endoscopic endonasal approaches, pediatric and adult CVJ spine surgery, and must understand and be able to treat the complex CSF dynamics present in CVJ pathology to provide the appropriate, optimal, and tailored treatment strategy for each individual patient, both child and adult. This is a comprehensive review of the history and evolution of the transoral approaches, extended transoral approaches, endoscopie assisted transoral approaches, endoscopie endonasal approaches, and CVJ reduction strategies. Incorporating these advancements, the authors update the initial algorithm for the treatment of CVJ abnormalities first published in 1980 by the senior author.

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“…CVJ abnormalities are especially relevant in the pediatric population. Many studies have documented the association between these lesions and disorders such as Down syndrome, osteogenesis imperfecta, juvenile rheumatoid arthritis, Klippel-Feil triad, and Morquio syndrome, among many others 16,19,24 Additionally, neoplastic lesions constitute an important category of CVJ pathology in children. Although usually benign, these tumors are often resistant to chemotherapy and radiation, thus requiring surgical excision.…”

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confidence: 99%

Predicting the limits of the endoscopic endonasal approach in children: a radiological anatomical study

Youssef

Smotherman

Kraemer

et al. 2016

PED

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OBJECT The endoscopic endonasal approach (EEA) has been established as an alternative approach to craniovertebral junction (CVJ) pathology in adults. The authors have previously described the nasoaxial line (NAxL) as an accurate predictor of the lower limit of the EEA to the CVJ in adults. The surgical anatomy limiting the EEA to the pediatric CVJ has not been well studied. Furthermore, predicting the lower limit of the EEA in various pediatric age groups is important in surgical planning. To better understand the anatomy affecting the EEA to the CVJ, the authors examined the skull base anatomy relevant to the EEA in children of different age groups and used the NAxL to predict the EEA lower limit in children. METHODS Axial brain CT scans of 39 children with normal skull base anatomy were reconstructed sagittally. Children were divided into 4 groups according to age: 3–6, 7–10, 11–14, and 15–18 years old. The intersection of the NAxL with the odontoid process of C-2 was described for each group. Analyses of variance were used to estimate the effect of age, sex, interaction between age and sex on different anatomical parameters relevant to the endonasal corridor (including the length of the hard palate [HPLe]), dimensions of choana and piriform aperture, and the length of the NAxL to C-2. The effect of the HPLe on the working distance of NAxL to the odontoid was also estimated using analysis of covariance, controlling for age, sex, and their interaction. RESULTS The NAxL extended to the odontoid process in 38 of the 39 children. Among the 39 children, the NAxL intersected the upper third of the odontoid process in 25 while intersecting the middle third in the remaining 13 children. The measurements of the inferior limits did not differ with age, varying between 9 and 11 mm below the hard palate line at the ventral surface of C-2. Significant increases in the size of the piriform aperture and choana and the HPLe were observed after age 10. The HPLe predicted the length of the NAxL (p < 0.0001). CONCLUSIONS The caudal limit of the EEA extends as far as the middle third of the odontoid process in children, as predicted by the NAxL. The most prominent increase in the size of the choana and piriform aperture occurs after age 10. The HPLe is a significant predictor of the working distance to C-2. Utilizing the NAxL preoperatively may help in planning the EEA to the CVJ in children.

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Craniocervical fusions in children

Cited by 75 publications

References 39 publications

Occipital condyle to cervical spine fixation in the pediatric population

Occipital condyle to cervical spine fixation in the pediatric population

Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update

Predicting the limits of the endoscopic endonasal approach in children: a radiological anatomical study

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