Successful delayed non-operative management of C2 neurosynchondrosis fractures in a pediatric patient: a case report and review of management strategies and considerations for treatment

Abstract

Upper cervical synchondrosis fractures are the most common types of cervical fractures in the pediatric population less than 7 years of age (Blauth et al (Eur Spine J 5:63-70, 1996); Connolly et al (Pediatr Radiol 25(Suppl1):S129-133, 1995); Mandabach et al (Pediatr Neurosurg 19(5):225-232, 1993); Schippers et al (Acta Neurochir 138:524-530, 1990)) The vast majority occur through the dentocentral or basilar synchondrosis. We present the second reported case in recent literature of a unilateral neurosynchondrosis fracture. The patient, a 4-year-old male, was initially managed conservatively with a rigid cervical collar for a period of 3 months. Despite multiple counseling sessions with family, the patient remained poorly compliant with cervical immobilization. After 3 months, imaging demonstrated partial fusion with persistent anterolisthesis of C2 on C3. The decision was made to place the child in external halo fixation as an attempt to achieve fusion prior to committing to internal surgical fixation and the associated sequelae. Immobilization with a hard cervical collar is often first line treatment. In the case of failed fusion, debate exists regarding surgical fixation in children. Occipito-atlanto-axial fusion leads to permanent loss of a significant degree of flexion, extension, and rotatory movement. The pediatric population has a strong propensity to fuse; however, compliance is often a barrier to conservative treatment due to age-related behavioral practices. We demonstrate that even with initial failed fusion and progression of deformity while in a cervical collar, conservative management with external halo fixation can potentially obviate the need for internal fixation.

Halo-Vesting in Preschool Aged Children with Synchondrosis Fracture: A Case Series which Explores the Current Techniques Associated with this Procedure

“…It has been shown that the younger the child is at the time of injury, the more likely the injury is to occur in the region of the upper cervical spine. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] This specific region has several characteristics that predispose it to such injuries including: increased ligamentous laxity, more horizontally oriented facet joints, less mature bone ossification, weak neck muscles, higher fulcrum of the cervical spine, and most importantly, the child's greater head-to-body ratio. It is because of this greater ratio that more forces are directed towards the junction between the larger head and the smaller body.…”

“…As a result of such a flexion injury, the fractured dense tends to be displaced anteriorly marked by the presence of a resultant variable angulation. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Extension injuries of the plate will occur rarely, being manifested only with the posterior displacement of the dense.…”

“…These undertakings are then monitored very closely during a radiographic follow-up. 1,[11][12][13]22,23 Despite the fact that there is a 43% complication rate and up to 10% of the failure of fusion was reported, Halo orthosis has been observed to be the most beneficial approach in the two limited clinical series. 12,18 New modifications in the Halo crown and pins' design, as well as its applied torque, have recently demonstrated a dramatic reduction in the complications attributed to this procedure.…”

“…Since this cartilaginous plate does not ossify until a child is 7-years-old, this developing region of the spine remains an area of potential weakness in preschool children. 5,[8][9][10][13][14][15][16][17]22,23 Although, rare in the overall incidence of spinal trauma, odontoid synchondrosis fractures are some of the more common fractures that occur in young children. The treatment of acute odontoid synchondrosis fractures in children depends on the amount of broken dense present, its forward displacement, and the angulation at which the injury is inflicted.…”

“…Modifications to the Halo crowns and pins in children as well as proper pin site wound care might be the key components to be addressed to ensure optimal results and negligible complications. [21][22][23][24][25][26] In certain situations, the posterior C1-C2 fixation may be warranted for individual cases with a complete translation of the broken dense. Fixation of C1-C2 may likewise be necessary, if there is a marked angulation that adequately shows the disruption of the corresponding posterior ligamentous structures.…”