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Os Odontoideum in Children: Treatment Outcomes and Neurological Risk Factors
Ilkka J Helenius1, Jennifer M Bauer2, Bram Verhofste3
1Department of Paediatric Orthopaedic Surgery, Turku University Hospital, Turku, Finland.
Insights
Atlantoaxial instability and spinal cord compression are key risk factors for neurological deficits in pediatric os odontoideum. Nonoperative care is safe for asymptomatic children, while spinal arthrodesis effectively treats symptomatic cases.
Area of Science:
- Pediatric Orthopedics
- Neurosurgery
- Spinal Surgery
Background:
- Os odontoideum in children presents unclear treatment outcomes and risk factors for neurological deficits.
- Neurological deficits can arise from atlantoaxial instability or compromised spinal cord space.
Purpose of the Study:
- To evaluate treatment outcomes and identify risk factors for neurological deficits in pediatric patients with os odontoideum.
- To compare the safety and efficacy of operative versus nonoperative management strategies.
Main Methods:
- A retrospective review of 102 pediatric patients with os odontoideum managed across 11 centers (2000-2016) with a minimum 2-year follow-up.
- Patients were stratified into nonoperative (n=31) and surgical (n=71) groups, with surgical intervention involving posterior cervical spinal arthrodesis for C1-C2 instability.
Main Results:
- Twenty-nine percent of patients presented with neurological deficits, strongly associated with radiographic atlantoaxial instability or reduced spinal cord space (RR 7.8).
- Nonoperative treatment was safe for asymptomatic patients without instability. Spinal arthrodesis improved neurological function scores in the surgical group.
- Surgical complications occurred in 21% of patients, including nonunion (12%) and new neurological deficits (4%).
Conclusions:
- Atlantoaxial instability and limited spinal cord space are significant risk factors for neurological deficits in pediatric os odontoideum.
- Nonoperative management is appropriate for asymptomatic children without these radiographic risk factors.
- Surgical spinal arthrodesis is an effective treatment for resolving neurological deficits in symptomatic pediatric os odontoideum cases.
Background:
Treatment outcomes and risk factors for neurological deficits in pediatric patients with an os odontoideum are unclear.
Methods:
We reviewed the data for 102 children with os odontoideum who were managed at 11 centers between 2000 and 2016 and had a minimum duration of follow-up of 2 years. Thirty-one children had nonoperative treatment, and 71 underwent instrumented posterior cervical spinal arthrodesis for the treatment of C1-C2 instability. Nonoperative treatment consisted of observation (n = 29) or immobilization with a cervical collar (n = 1) or halo body jacket (n = 1). Surgical treatment consisted of atlantoaxial (n = 50) or occipitocervical (n = 21) arthrodesis. One patient also underwent transoral odontoidectomy.
Results:
Thirty children (29%) presented with neurological deficits, 28 of whom had radiographic atlantoaxial instability (atlantoaxial distance >5 mm) or limited space (≤13 mm) available for the spinal cord (risk ratio, 7.8 [95% confidence interval, 2.0 to 31] compared with children with no radiographic risk factors). The 27 children without neurological deficits or atlantoaxial instability at presentation underwent nonoperative treatment and remained asymptomatic. Of the initial nonoperative cohort, one child developed atlantoaxial instability, and another had a persistent neurological deficit; both children underwent spinal arthrodesis during the study period. One child with cervical instability declined surgery and remained asymptomatic. Spinal fusion occurred in 68 patients in the surgical group by the end of the study period (mean, 3.7 years; range, 2.0 to 11.8 years). Surgical complications occurred in 21 children, including nonunion in 12, new neurological deficits in 4, cerebrospinal fluid leak in 2, symptomatic instrumentation requiring removal 2, and vertebral artery injury in 1. Nine children underwent revision surgery. In the surgical group, Japanese Orthopaedic Association neurological function scores improved significantly from preoperatively to the latest follow-up for the upper extremities (p = 0.026) and lower extremities (p = 0.007).
Conclusions:
The risk of developing a neurological deficit was strongly associated with atlantoaxial instability and limited space available for the spinal cord in children with os odontoideum. Nonoperative treatment was safe for asymptomatic patients without atlantoaxial instability. Spinal arthrodesis resolved the neurological deficits of children with symptomatic os odontoideum.
Level Of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
