Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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).</jats:p><jats:p>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).</jats:p><jats:p>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).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>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.</jats:p></jats:sec>

Cervical Pediatric Spine Trauma Managed With Open Spinal Fixation and Instrumentation and a Review of the Literature

“…A multicenter study investigating the long-term effects of rigid instrumentation and surgical fusion found that 95% of patients had complete or significant resolution of neurologic symptoms following instrumentation, with 66% of patients demonstrating continued vertical growth of the subaxial spine [ 11 ]. Likewise, a retrospective review of 184 anterior- and posterior-approach cervical spine instrumentation and fusion found that 96.7% of children improved or stabilized neurologic outcome following traumatic injury [ 14 ]. Anterior cervical approaches have been less commonly studied but are also promising.…”

“…Surgical approaches have proven to be successful in pediatric cervical injury cases. They have been used in cases of spinal fracture-dislocations, burst fractures, compression fractures with concomitant deformity, and atlanto-occipital dislocation (Table 1) [1,[6][7][8][9][10][11][12][13][14][15]. The most common surgical intervention approach is posterior cervical fusion and occipitocervical fusion using autograft or allograft (94% vs. 80% fusion rate) has an overall fusion rate of 93% based on a systemic literature review [16].…”

Narcotrend-guided intraoperative care of a Trisomy 21 paediatric patient who underwent occipitocervical fusion

“…Due to the limited space and intimate anatomic relationship, posterior cervical spine surgery inherently puts neural structures at risk. Reported incidence of neurological complications associated with these procedures in the paediatric population is variable (0, 0.3%, 3.3%) 3–5…”

Suggestion For a New Classification of Postoperative Neurological Complications (CPNC) in Neurosurgery

“…As it is known, a recovery of neurological disturbances and consequently of functional restriction can take a long time [11]. The neurological status on the day of discharge from acute care hospital mostly is not a nal result and can be signi cantly improved due to medical rehabilitation [25]. Therefore we decided to establish a su x "r" for de ning the long-term outcome.…”

“…Obviously, the fact that improvement of neurological disturbances can take a long time [11,25] and the neurological state at the time of discharge from acute care hospital mostly is not a nal result, leads to the requirement of evaluation of neurological state after completed rehabilitation. For this purpose, the suggested su x "r" appears to be useful for observation of neurological complications in the follow-up period and determination of the nal outcome.…”