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Craniovertebral junction fixation in children less than 5 years
Patrick J Grover1, Lauren S Harris2, Dominic N P Thompson2
1Department of Neurosurgery, Great Ormond Street Hospital, 34 Great Ormond Street, London, WC1N 3JH, UK. patrick.grover@doctors.org.uk.
Insights
Semi-rigid fixation techniques, including cable fixation with bone grafts and halo orthosis, achieve high fusion rates and good outcomes for craniovertebral instability in children under five years old. This approach offers a safe alternative when traditional methods are not feasible.
Area of Science:
- Neurosurgery
- Pediatric Orthopedics
- Spinal Surgery
Background:
- Craniovertebral instability in young children often requires modified management compared to adults.
- Rigid fixation is the standard, but anatomical limitations in very young patients necessitate alternative approaches.
Purpose of the Study:
- To evaluate the safety and efficacy of semi-rigid fixation techniques for craniovertebral instability in children under five years of age.
- To present a single-center experience with craniocervical fixation in this pediatric population.
Main Methods:
- Retrospective review of 26 children under five years old who underwent atlantoaxial (AA) or occipitocervical (OC) fixation.
- Fusion assessment via computed tomography or flexion-extension X-rays.
- Analysis of fixation methods, including sublaminar cable fixation, bone grafts, and halo-body orthosis.
Main Results:
- High initial fusion rate of 91%, reaching 100% after re-operations.
- 92% of patients were neurologically stable or improved post-surgery.
- Good overall outcomes in 21 patients, with manageable morbidity (e.g., pin site issues).
Conclusions:
- Semi-rigid fixation techniques provide high fusion rates and favorable outcomes in children under five with craniovertebral instability.
- Autologous calvarial bone graft secured with wire cables and halo external orthosis is a safe and effective alternative when traditional screw instrumentation is not feasible.
Purpose:
Whilst rigid fixation for craniovertebral instability is the gold standard, in very young, small children conventional management may have to be modified. We present a single-centre experience of craniocervical fixation in children under 5 years.
Methods:
A retrospective review of cases that had undergone atlantoaxial (AA) or occipitocervical (OC) fixation aged under 5 years. Fusion was assessed using computerised tomography or flexion extension X-rays.
Results:
Twenty-six children (median age 2.3, range 0.8-4.9 years, 19 under the age of 3) underwent OC (n = 19) or AA (n = 7) fusion between 1999 and 2016. Pathology comprised 17 congenital, five trauma, two tumour and two post-infection cases. Twenty-one patients underwent sublaminar cable fixation with calvarial, autologous bone graft and halo-body orthosis immobilisation. An occipital plate and rods to sublaminar wire construct were used in four cases. A rigid instrumented fixation with occipital plate and C2 pedicle screws was utilised in one case. Follow-up was for a median of 2.8 years (range 0.03-16.3 years). Initial fusion rate was 91%, reaching 100% following two re-operations. Ninety-two per cent of patients were neurologically stable or improved following surgery. Twenty-one patients had a good overall outcome. Two patients had post-operative neurological deteriorations, and four died due to non-procedure related causes. Pin site morbidity secondary to halo use occurred in five cases.
Conclusion:
High fusion rates with good outcomes are achievable using semi-rigid fixation in the under 5-year-olds. Full thickness, autologous calvarial bone graft secured with wire cables and halo external orthosis offers a safe and effective alternative technique when traditional screw instrumentation is not feasible. These slides can be retrieved under Electronic Supplementary Material.
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