Spinal instrumentation in infants, children, and adolescents: a review

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The evolution of pediatric spinal instrumentation has progressed in the last 70 years since the popularization of the Harrington rod showing the feasibility of placing spinal instrumentation into the pediatric spine. Although lacking in pediatric-specific spinal instrumentation, when possible, adult instrumentation techniques and tools have been adapted for the pediatric spine. A new generation of pediatric neurosurgeons with interest in complex spine disorder has pushed the field forward, while keeping the special nuances of the growing immature spine in mind. The authors sought to review their own experience with various types of spinal instrumentation in the pediatric spine and document the state of the art for pediatric spine surgery.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors retrospectively reviewed patients in their practice who underwent complex spine surgery. Patient demographics, operative data, and perioperative complications were recorded. At the same time, the authors surveyed the literature for spinal instrumentation techniques that have been utilized in the pediatric spine. The authors chronicle the past and present of pediatric spinal instrumentation, and speculate about its future.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The medical records of the first 361 patients who underwent 384 procedures involving spinal instrumentation from July 1, 2007, to May 31, 2018, were analyzed. The mean age at surgery was 12 years and 6 months (range 3 months to 21 years and 4 months). The types of spinal instrumentation utilized included occipital screws (94 cases); C1 lateral mass screws (115 cases); C2 pars/translaminar screws (143 cases); subaxial cervical lateral mass screws (95 cases); thoracic and lumbar spine traditional-trajectory and cortical-trajectory pedicle screws (234 cases); thoracic and lumbar sublaminar, subtransverse, and subcostal polyester bands (65 cases); S1 pedicle screws (103 cases); and S2 alar-iliac/iliac screws (56 cases). Complications related to spinal instrumentation included hardware-related skin breakdown (1.8%), infection (1.8%), proximal junctional kyphosis (1.0%), pseudarthroses (1.0%), screw malpositioning (0.5%), CSF leak (0.5%), hardware failure (0.5%), graft migration (0.3%), nerve root injury (0.3%), and vertebral artery injury (0.3%).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Pediatric neurosurgeons with an interest in complex spine disorders in children should develop a comprehensive armamentarium of safe techniques for placing rigid and nonrigid spinal instrumentation even in the smallest of children, with low complication rates. The authors’ review provides some benchmarks and outcomes for comparison, and furnishes a historical perspective of the past and future of pediatric spine surgery.</jats:p></jats:sec>

A 3D-Printed Model-Assisted Cervical Spine Instrumentation after Tumor Resection in a 4-Year-Old Child: A Case Report

“…In fact, posterior cervical spinal fixation in very young children is challenging not only due to anatomical considerations, but especially due to unavailability of appropriate instrumentation. The use of rod-screw systems designed for adult spinal fixation may lead to iatrogenic injury of the small and fragile posterior spinal and neural elements and result in an unsuccessful fixation and neurologic deterioration in patients under the age of 8 years [5, 11]. Lateral mass screws, therefore, are avoided in posterior cervical fixation in patients under the age of 8 years, and to our knowledge, the youngest patient reported to undergo a successful lateral mass screw placement was 8 years old [5, 9].…”

“…Due to the mobile deformity and failure of posterior elements, posterior release, reduction, and fixation were suggested in order to avoid an extensive occipito-cervico-thoracic fusion in the growing skeleton [8]. As specific spinal instrumentation for posterior cervical fixation in the pediatric population under the age of 8 years [5, 9] could not be obtained, virtual 3D preoperative planning was used to simulate operative conditions and test possible fixation techniques (EBS Version 3.1.0DEV4[x64], Ekliptik Ltd.). The 3D virtual model showed a pure kyphotic deformity of 30° from C2 to C5 with kyphosis apex at C4 and minimal facet displacement.…”

“…Resection of the tumor in the upper cervical spine may require multilevel laminectomy, which, without internal fixation, may result in postoperative spinal decompensation [3] and cervical myelopathy due to anterior spinal cord compression and stretching [4]. However, surgeons may try to avoid cervical spinal instrumentation in the pediatric population under the age of 8 years due to anatomical constraints and unavailability of specific implants [5]. Lately, preoperative 3D modeling and printing have been shown to improve accuracy and provide an improved sense of spinal anatomy [6], especially in the treatment of spinal deformity in children [7].…”

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…”

Pediatric Scoliosis Surgery—A Comprehensive Analysis of Treatment-Specific Variables and Trends in Latvia

“…The criterion for the final analysis was primary scoliosis correction within the period of interest. In concordance with previous studies, patients up to age 21 (≤21 years) were included to confine the analysis to the pediatric spectrum and minimize the potential influence of degenerative scoliotic changes at higher ages [23]. Cases with a postoperative stay (from the first day after the surgery) for more than 3 weeks were excluded, since these constituted complicated cases that required multiple follow up surgeries and were, as exceptions, not representative for the majority of cases.…”