Pseudarthrosis in modern instrumented pediatric cervical spine fusion

Instrumented fusion for management of pediatric cervical spine conditions has significant morbidity risk due to rare underlying pathologies, small anatomical dimensions, limited bony surface area, poor bone quality, and potential effects on future growth. Pediatric cervical spine fusions are often subject to pseudarthrosis, reportedly as high as 38%. The aim of this study was to evaluate a single institution's clinical experience with modern instrumented cervical spine fusion in pediatric patients to identify risk factors and management techniques for pseudarthrosis.

Medical records were retrospectively reviewed for pediatric patients (age ≤ 21 years) who underwent instrumented cervical spinal fusion using current fixation techniques at a single institution between 2005 and 2023. Demographic and diagnosis characteristics, surgical details, and follow-up clinical and imaging findings were collected.

Overall, 150 patients (82 male, mean age at surgery 11.7 ± 5.0 years) were included. Underlying diagnoses included 51 patients with congenital deformity, 35 with instability, 24 with traumatic injury, 22 with tumor, and 18 with os odontoideum. The mean duration of follow-up was 5.9 ± 3.7 years. Twelve patients (8%) experienced nonunion, defined by a lack of osseous bridging (n = 6), screw lucency (n = 5), or both (n = 1) on CT or radiography. Eight patients in the nonunion group had an underlying syndromic diagnosis (p = 0.03), including 6 of 12 patients (50%) with Down syndrome (p < 0.005). The median time from index surgery to pseudarthrosis diagnosis was 11 months (range 3 months-3.07 years). Eleven secondary procedures were performed to address pseudarthrosis, with instrumentation revision in 10, autograft used in 6, and recombinant bone morphogenetic protein used in 7. A postoperative halo was used in 36% of revisions. One patient who underwent a secondary procedure for pseudarthrosis required a subsequent revision.

Pediatric cervical spinal fusions had a pseudarthrosis rate of 8%. Syndromic patients, specifically patients with Down syndrome, have higher risk of nonunion and thus require counseling in this regard, as well as closer follow-up. However, syndromic patients with Ehler-Danlos and neurofibromatosis were not at increased risk of nonunion. The pathology and etiology of instability was not a significant contributor to pseudarthrosis. In most cases of nonunion, a single revision surgery was sufficient treatment.