Technical Advances in Pediatric Craniovertebral Junction Surgery

Oppenlander, Mark E.; Kalyvas, James; Sonntag, Volker K. H.; Theodore, Nicholas

doi:10.1007/978-3-319-01065-6_6

Cited by 6 publications

(10 citation statements)

References 25 publications

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“…8,9,[12][13][14]16,17,19,21,25,32 One type of upper cervical spine injury, atlantooccipital dislocation (AOD), is a severe injury associated with high mortality rates. 1,2,11,12,[16][17][18][19][20]22,24 In postmortem examinations, evidence of AOD is present in 20%-31% of deaths due to cervical spine injuries. 6 In recent decades, improvements in emergency management, transport, and recognition of AOD have resulted in higher survival rates.…”

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confidence: 99%

Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle–C1 interval

Martinez-del-Campo

Kalb

Soriano-Baron

et al. 2016

SPI

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OBJECT Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle–C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD. METHODS A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines. RESULTS The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 ± 16 years (range 19–87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 ± 9.7 years (range 20–56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 ± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 ± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 ± 0.18 mm (range 1.5 mm–6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 ± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively. CONCLUSIONS The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.

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Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle–C1 interval

Martinez-del-Campo

Kalb

Soriano-Baron

et al. 2016

SPI

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“…Long-term follow-up assessment of growth, curvature, alignment, and stability of the cervical spine after OCF in children is an unavoidable subject in most pediatric series. The clinical relevance of the potential effects of arthrodesis in the pediatric spine has been discussed extensively, [3][4][5][6][7]9,11,19,[21][22][23][24][25][26] but only a few studies have meticulously evaluated growth, curvature, and alignment 3,22,25 at the craniovertebral junction and the upper cervical spine in young patients in whom short constructs have been placed. So far, no study has reported significant changes in radiographic or clinical findings after a long follow-up period.…”

Section: Discussion Concerns Following Occipitocervical Arthrodesis Imentioning

confidence: 99%

Pediatric occipitocervical fusion: long-term radiographic changes in curvature, growth, and alignment

Martinez-del-Campo¹,

Turner²,

Soriano-Baron³

et al. 2016

PED

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OBJECTIVE The authors assessed the rate of vertebral growth, curvature, and alignment for multilevel constructs in the cervical spine after occipitocervical fixation (OCF) in pediatric patients and compared these results with those in published reports of growth in normal children. METHODS The authors assessed cervical spine radiographs and CT images of 18 patients who underwent occipitocervical arthrodesis. Measurements were made using postoperative and follow-up images available for 16 patients to determine cervical alignment (cervical spine alignment [CSA], C1–7 sagittal vertical axis [SVA], and C2–7 SVA) and curvature (cervical spine curvature [CSC] and C2–7 lordosis angle). Seventeen patients had postoperative and follow-up images available with which to measure vertebral body height (VBH), vertebral body width (VBW), and vertical growth percentage (VG%—that is, percentage change from postoperative to follow-up). Results for cervical spine growth were compared with normal parameters of 456 patients previously reported on in 2 studies. RESULTS Ten patients were girls and 8 were boys; their mean age was 6.7 ± 3.2 years. Constructs spanned occiput (Oc)–C2 (n = 2), Oc–C3 (n = 7), and Oc–C4 (n = 9). The mean duration of follow-up was 44.4 months (range 24–101 months). Comparison of postoperative to follow-up measures showed that the mean CSA increased by 1.8 ± 2.9 mm (p < 0.01); the mean C2–7 SVA and C1–7 SVA increased by 2.3 mm and 2.7 mm, respectively (p = 0.3); the mean CSC changed by −8.7° (p < 0.01) and the mean C2–7 lordosis angle changed by 2.6° (p = 0.5); and the cumulative mean VG% of the instrumented levels (C2–4) provided 51.5% of the total cervical growth (C2–7). The annual vertical growth rate was 4.4 mm/year. The VBW growth from C2–4 ranged from 13.9% to 16.6% (p < 0.001). The VBW of C-2 in instrumented patients appeared to be of a smaller diameter than that of normal patients, especially among those aged 5 to < 10 years and 10–15 years, with an increased diameter at the immediately inferior vertebral bodies compensating for the decreased width. No cervical deformation, malalignment, or detrimental clinical status was evident in any patient. CONCLUSIONS The craniovertebral junction and the upper cervical spine continue to present normal growth, curvature, and alignment parameters in children with OCF constructs spanning a distance as long as Oc–C4.

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“…Rigid cervical collars, which are potentially harmful with distraction injuries, were avoided. 39,40 Halo vest orthoses were used in some cases when immediate operative intervention was not possible.…”

Section: Methodsmentioning

confidence: 99%

“…The incorporation of structural grafts strengthens the construct and improves arthrodesis rates. 3,4,6,7,17,40,57 However, the most appropriate fixation strategy must be tailored to each patient; surgeons should consider the underlying pathology, size of the spinal osseous structures, any anatomical variations, and extent of pathology. The size of the bone at sites of fixation is most often dictated by the patient's age and any comorbid congenital syndrome.…”

mentioning

confidence: 99%

“…Adverse effects on spinal alignment, stability, and cervical spine growth have been described. 3,4,14,15,27,36,40,49,57 Although several pediatric series on this topic have been previously published, 10,15,23,24,36,41,57 results need to be interpreted cautiously because of relatively small sample sizes. 3,4,12,17,26,36,38,39,44,49 To our knowledge, this study represents one of the largest single-surgeon case series to date describing OC fixation in the pediatric population.…”

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Pediatric occipitocervical fixation: radiographic criteria, surgical technique, and clinical outcomes based on experience of a single surgeon

Martinez-del-Campo¹,

Turner²,

Rangel-Castilla³

et al. 2016

PED

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OBJECTIVE If left untreated, occipitocervical (OC) instability may lead to serious neurological injury or death. Open internal fixation is often necessary to protect the neurovascular elements. This study reviews the etiologies for pediatric OC instability, analyzes the radiographic criteria for surgical intervention, discusses surgical fixation techniques, and evaluates long-term postoperative outcomes based on a single surgeon's experience. METHODS The charts of all patients < 18 years old who underwent internal OC fixation conducted by the senior author were retrospectively reviewed. Forty consecutive patients were identified for analysis. Patient demographic data, OC junction pathology, radiological diagnostic tools, surgical indications, and outcomes are reported. RESULTS The study population consisted of 20 boys and 20 girls, with a mean age of 7.3 years. Trauma (45% [n = 18]) was the most common cause of instability, followed by congenital etiologies (37.5% [n = 15]). The condyle-C1 interval had a diagnostic sensitivity of 100% for atlantooccipital dislocation. The median number of fixated segments was 5 (occiput–C4). Structural bone grafts were used in all patients. Postsurgical neurological improvement was seen in 88.2% (15/17) of patients with chronic myelopathy and in 25% (1/4) of patients with acute myelopathy. Preoperatively, 42.5% (17/40) of patients were neurologically intact and remained unchanged at last follow-up, 42.5% (17/40) had neurological improvement, 12.5% (5/40) remained unchanged, and 2.5% (1/40) deteriorated. All patients had successful fusion at 1-year follow-up. The complication rate was 7.5% (3/40), including 1 case of vertebral artery injury. CONCLUSIONS Occipitocervical fixation is safe in children and provides immediate immobilization, with excellent survival and arthrodesis rates. Of the radiographic tools evaluated, the condyle-C1 interval was the most predictive of atlantooccipital dislocation.

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Technical Advances in Pediatric Craniovertebral Junction Surgery

Cited by 6 publications

References 25 publications

Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle–C1 interval

Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle–C1 interval

Pediatric occipitocervical fusion: long-term radiographic changes in curvature, growth, and alignment

Pediatric occipitocervical fixation: radiographic criteria, surgical technique, and clinical outcomes based on experience of a single surgeon

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