Pediatric Atlantoaxial Instability: Management with Screw Fixation

Wang, Jin; Vokshoor, Amir; Stanley, Kim; Elton, Scott; Kosnik, Edward J.; Bartkowski, Henry M.

doi:10.1159/000028766

Cited by 89 publications

(50 citation statements)

References 29 publications

(34 reference statements)

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“…In the past, a C1-C2 fusion using autogenous iliac crest and sublaminar wiring such as Brooks-Jenkins, Gallie, and Sonntag have been reported [24][25][26], but this technique resulted in non-union in most cases, especially for patients with Down syndrome [1,2]. C1-2 transarticular screw fixation (Magerl technique [3]) and its effectiveness in pediatric patients have been described [8,16,17]. Similarly, some studies reported that the C1 lateral screw and C2 pedicle screw technique (Goel-Harms constructs [4,5]) provide stabilization and promotes fusion in pediatric patients with AAI [9][10][11][12][13].…”

Section: Discussionmentioning

confidence: 99%

“…Magerl et al [3] first proposed the use of C1-C2 transarticular screws in adults, and an alternative technique, namely C1 lateral mass screws and C2 pedicle screws [4,5] or C2 translaminar screws [6] has been reported. More recently, these techniques are being used in pediatric patients [7][8][9][10][11][12][13][14][15][16][17]; however, there are no detailed reports on the risks with these techniques when used in children. Furthermore, the medical community does not fully understand the long-term effects of posterior cervical spine fusion in the skeletally immature spine, and there are only a few published articles on these effects [18,19].…”

Section: Introductionmentioning

confidence: 99%

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Complications and outcomes of posterior fusion in children with atlantoaxial instability

et al. 2011

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Introduction Atlantoaxial instability (AAI) is an uncommon disease in children. Surgical treatment of pediatric patients with AAI poses a challenge to spine surgeons because of the patients' immature bone quality, extensive anatomical variability, and smaller osseous structures. In this study, the authors report complications and outcomes after posterior fusion in children with AAI. MethodsThe authors reviewed medical records of patients 13 years old and younger with AAI who underwent posterior fusion in the Nagoya Spine Group hospitals, a multicenter cooperative study group, from January 1995 to December 2007. We identified 11 patients who underwent posterior fusion, and analyzed their clinical outcomes and complications. To determine if vertical growth within the construct continued after posterior fusion, in three patients at 5 or more years following occipito-cervical (O-C) fusion, intervertebral disc heights and vertebral heights between the fused and nonfused levels were compared on the final follow-up. Results The initial surgeries were C1-C2 fusions in six patients and O-C fusion in five patients. Successful fusion ultimately occurred in all patients, however, the complication rate related to the operations was high (64%). Complications included neurologic deterioration, pedicle fracture with pedicle screw insertion, C1 posterior arch fracture with lateral mass screw insertion, perforation of the skull with a head pin placement, and fusion extension to adjacent vertebrae. Two patients required reoperation. The mean fixed and non-fixed intervertebral disc heights on the final follow-up were 2.6 and 5.3 mm, respectively, showing that the disc height of the fixed level was less than the non-fused level. Each vertebra lengthened similarly between fused and non-fused levels except for C2 which had a lower growth rate than the other vertebrae. Conclusions A high complication rate should be anticipated after posterior fusion in children with AAI. Careful consideration should be paid to pediatric patients with AAI treated by screw and/or rod systems. After posterior fusion in pediatric patients, each vertebra continued to grow, in contrast the disc height decreased between fused levels.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Complications and outcomes of posterior fusion in children with atlantoaxial instability

et al. 2011

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“…Diminutive osseous and ligamentous structures, as well as the peculiar configuration of vertebral components, the presence of congenital malformations with possible abnormal vertebral artery location, and the need for external immobilization and the potential for its complications have made it important to critically evaluate instrumentation and its incorporation into the management of pediatric patients who require craniocervical stabilization. 4,6,16,22,35,37 In the past, the use of bone (rib or iliac crest) with …”

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confidence: 99%

Craniocervical fusions in children

Menezes¹

2012

PED

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The surgical management of craniovertebral junction (CVJ) instability in pediatric patients presents unique challenges. As compared with the adult patient, the anatomical variations of the CVJ in the pediatric patient are significant, complicate the approach, and limit the use of internal fixation. Diminutive osseous and ligamentous structures and syndromic craniovertebral abnormalities complicate the issue. Advances in imaging analysis and instrumentation have improved the armamentarium for managing the pediatric patient who requires craniocervical stabilization. In this paper, the author's experience of performing more than 850 pediatric CVJ fusions is reviewed. This work includes the indications for atlantoaxial arthrodesis and occipitocervical fusion. Early atlantoaxial fusions were performed using interlaminar rib graft fusion, and more recently using either transarticular screw fixation in the older patient, or lateral mass screws at C-1 and rod fixation with either C-2 pars interarticular screw fixation or pedicle screw fixation. A C-2 translaminar screw fixation is also described. Occipitocervical fusions are performed with rib grafts in patients younger than 6 years of age. Subsequently, above that age, contoured loop fixation was performed, and in the past 8–10 years, screw and rod fixation was used. Abnormal spine growth was not observed in children who underwent craniocervical stabilization below the age of 5 years (clearly the bone grew with the patient). However, no deleterious effects were noted in the children treated with rigid instrumentation. The success rate for bone fusion alone was 98%. The author's success rate with rigid instrumentation is nearly 100%. A detailed review of the technique of fusion is presented, as well as the indications and means of avoidance of complications, their prevention, and management.

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“…11,82,138,140 While there was a dearth of publications related to the use of allograft in pediatric cervical spine fusions for the 2 decades that followed the early failures reported in the 1980s, there has been a resurgence in interest over the most recent decade corresponding to the widespread use of rigid internal fixation techniques and the availability of BMP. 56,69,73,78,88,151 Emboldened by the greater fusion rates associated with screw-based constructs, with or without the use of BMP, there has been a sharp rise in publications describing OCF and PCF in children and adults. Our review confirmed that fusion rates greater than 90% have been routinely reported with pediatric OCF and PCF when allograft is used with rigid internal fixation.…”

Section: Publication Biasmentioning

confidence: 99%

Allograft versus autograft for pediatric posterior cervical and occipito-cervical fusion: a systematic review of factors affecting fusion rates

Reintjes

Amankwah

Rodríguez

et al. 2016

PED

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OBJECT Fusion rates are high for children undergoing posterior cervical fusion (PCF) and occipito-cervical fusion (OCF). Autologous bone has been widely used as the graft material of choice, despite the risk of donor-site morbidity associated with harvesting the bone, possibly because very low fusion rates were reported with posterior allograft cervical fusions in children several decades ago. Higher overall fusion rates using allograft in adults, associated with improvements in internal fixation techniques and the availability of osteoinductive substances such as bone morphogenetic protein (BMP), have led to heightened enthusiasm for the use of bank bone during pediatric PCF. A systematic review was performed to study factors associated with successful bone fusion, including the type of bone graft used. METHODS The authors performed a comprehensive PubMed search of English-language articles pertaining to PCF and OCF in patients less than 18 years old. Of the 561 abstracts selected, 148 articles were reviewed, resulting in 60 articles that had sufficient detail to be included in the analysis. A meta-regression analysis was performed to determine if and how age, fusion technique, levels fused, fusion substrate, BMP use, postoperative bracing, and radiographic fusion criteria were related to the pooled prevalence estimates. A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. RESULTS A total of 604 patients met the specific inclusion and exclusion criteria. The overall fusion rate was 93%, with a mean age of 9.3 years and mean follow-up of 38.7 months. A total of 539 patients had fusion with autograft (94% fusion rate) and 65 patients with allograft (80% fusion rate). Multivariate meta-regression analysis showed that higher fusion rates were associated with OCF compared with fusions that excluded the occiput (p < 0.001), with the use of autograft instead of allograft (p < 0.001), and with the use of CT to define fusion instead of plain radiography alone. The type of internal fixation, the use of BMP, patient age, and the duration of follow-up were not found to be associated with fusion rates in the multivariate analysis. CONCLUSIONS Fusion rates for PCF are high, with higher rates of fusion seen when autograft is used as the bone substrate and when the occiput is included in the fusion construct. Further study of the use of allograft as a viable alternative to autograft bone fusion is warranted because limited data are available regarding the use of allograft in combination with more rigid internal fixation techniques and osteoinductive substances, both of which may enhance fusion rates with allograft.

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Pediatric Atlantoaxial Instability: Management with Screw Fixation

Cited by 89 publications

References 29 publications

Complications and outcomes of posterior fusion in children with atlantoaxial instability

Complications and outcomes of posterior fusion in children with atlantoaxial instability

Craniocervical fusions in children

Allograft versus autograft for pediatric posterior cervical and occipito-cervical fusion: a systematic review of factors affecting fusion rates

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