The anterior cervical approach in pediatric patients: indications and outcomes

Although the anterior approach to cervical spine surgery is an important tool for managing pediatric spine conditions, there is limited literature on the topic. The aim of this single-institution study was to analyze the indications, surgical techniques, complication rates, and outcomes of anterior cervical spine surgery in pediatric patients.

A single-center retrospective review of pediatric patients (age < 18 years) who underwent anterior cervical spine surgery from 2010 to 2022 was performed. Data collected included demographics, surgical indications, presenting symptoms, operative techniques and outcomes, fusion rate as defined in the postoperative note, complications, returns to the operating room, and rates of proximal/distal junctional issues.

A total of 64 patients (mean age 13.3 ± 3.9 years, 73.4% male) with a mean follow-up period of 16 months were evaluated. The most common indication for surgery was trauma (73.4%), followed by deformity/nontraumatic instability (21.9%) and neoplasia (4.7%). Syndromic etiologies necessitating surgery were present in 9.4% of patients (Klippel-Feil syndrome [6.2%], achondroplasia [1.6%], and diastrophic dysplasia [1.6%]). Some patients (35.9%) had neurological deficits at presentation (6.2% motor only, 4.7% sensory only, 25.0% with motor and sensory deficits). Most patients (85.9%) underwent anterior surgery alone, whereas 14.1% underwent staged anterior surgery followed by posterior fixation. Two-level fusions were most common (45.3%), followed by single-level fusions (26.5%) and fusions of 3 or more levels (28.1%). An anterior plate was used in most cases (98.4%), 10.9% of which were small static cervical plate constructs. A synthetic cage was used in 14.1% of cases, most of which were polyetheretherketone (88.9%). A structural allograft was used in 85.9% of cases. Perioperative complications affected 9.4% of patients (hoarseness [4.7%], dysphagia [1.6%], hematoma [1.6%], and vascular injury [1.6%]). Arthrodesis across the anterior instrumented levels was successful in 98.4% of patients. Pseudarthrosis requiring revision surgery occurred in 1 patient within 1 year of the index surgery. Proximal junctional kyphosis was observed in 10.9% of patients, and 6.4% of patients required an unplanned return to the operating room (C3 pseudarthrosis [1.6%], hematoma evacuation [1.6%], and posterior implant failure [3.1%]).

The authors report their single-institution experience with pediatric anterior cervical spine surgery. Most patients underwent anterior instrumented fusion alone with high rates of success. Larger, multicenter studies are needed to better elucidate factors that might contribute to unfavorable outcomes.