Posterior cervical fusion in children

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1 Posterior cervical fusion in children JOE M. MCWHORTER, M.D., EBEN ALEXANDER, JR., M.D., COURTLAND H. DAVIS, JR., M.D., AND DAVID L. KELLY, JR., M.D. Section on Neurosurgery, Department of Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina Six cases of posterior cervical fusion with rib grafts in children are reported. Four of the children had sustained cervical spine injuries in accidents, and two had congenital absence of the odontoid. Three-level fusions (C 1-3) were done in four children, and four-level fusions (C1-4) in two. One child died of unrelated causes 3 months after the operation. The other five children have been followed for 5 to 13 years. All are doing well and each has a remarkably supple, stable neck and no neurological deficit. KEY WORDS 9 cervical spine fusion 9 congenital absence of odontoid 9 spine injuries in children 9 cervical spine fracture necessity for cervical spine fu- Ts~n in children is relatively rare, -Land reports of it in the literature are few. In this age of high-speed accidents, however, the relative frequency of cervical spine injuries in children is increasing, and the best method for treating such injuries should be defined. The care of children with vertebral and spinal cord injuries should be directed first toward relief of spinal cord compression and reduction of the deformity, then toward adequate immobilization? In 1958, Alexander, et al., 1 reported a method of posterior cervical spine fusion used at the North Carolina Baptist Hospital (NCBH). Six of all patients treated by that method between 1957 and 1974 were children. Those six form the basis of this report. Operative Technique The patient is anesthetized while in skeletal traction, and the surgeon maintains strict control of the position of the head and neck during intubation to prevent undue motion. After satisfactory anesthesia has been achieved, the patient is turned to the prone position, again with head and neck movement controlled with traction; vertebral alignment is confirmed by x-ray film. Through a vertical midline incision the spinous processes and laminae of the vertebrae to be fused are exposed by sharp dissection, and extraneous tissue is removed from them. Small bits of the laminae are removed with a Kerrison punch to facilitate bilateral passage of No. 20 stainless steel wire below the laminal arches. The main stabilizing wires are No. 18 stainless steel wires passed bilaterally through the spinous process of the vertebra above the dislocation, brought around behind the spinous process of the dislocated vertebra, and secured in place. These wires maintain reduction. In a fusion for an odontoid fracture or for congenital absence of the odontoid, a stabilizing wire is passed around the arch of C-1 on each side of the midline, and secured behind the spinous process of C-2. An incision is then made in the posterolateral chest wall over the rib to be used for grafting, usually the eighth or ninth rib. A 6- to 8-cm portion of rib is resected and the d. Neurosurg. / Volume 45 / August, l

2 J. M. McWhorter, et al. wound closed. The rib is trimmed to the desired length, split lengthwise (or if the whole thickness of the rib is desired, cut in two equal lengths), and laid on each side over the laminal arches of the vertebrae to be fused. The grafts are secured in place by twisting the previously placed No. 20 stainless steel wires over them, and the wound is then closed in layers. Skeletal traction is maintained with a minimum weight of 2 to 4 lb until postoperative swelling subsides and the patient can comfortably be fitted with a four-poster brace. The brace is worn when the patient is upright and a Thomas Collar when in bed until satisfactory fusion has occurred, usually for 4 months. Case 1 Case Reports An 18-month-old girl was thrown against the dashboard and windshield during an automobile accident. She did not lose consciousness. She was admitted to a local hospital where examination showed flaccid paralysis of the lower extremities and normal upper extremities. Several hours later she had an episode of respiratory distress and was noted to have no intercostal muscle function. Cervical spine films showed atlantoaxial dislocation with separation of the odontoid from the body of C-1 by approximately 8 mm. Neither Gardner-Wells traction nor an infant halo satisfactorily reduced the fracture, and she was transferred to NCBH 6 days after the injury. First Admission. At that time, she was breathing diaphragmatically, and had good function in the upper extremities but flaccid lower extremities and a sensory level at T-1. Cervical spine films showed considerable distraction of C-1 from C-2, and the odontoid lying below the level of C-1. The halo was removed, and Gardner-Wells traction was applied with 2 lb of weight. The next day a myelogram showed no evidence of a block. A posterior cervical fusion of C1-3 was done 3 days later with rib grafts. Postoperative x-ray films showed satisfactory alignment of C-1 to C-2. The patient was kept in Gardner-Wells traction for several days and then placed in a soft cervical collar. Her postoperative course was benign. When she was discharged, her lower extremities had no motor function; her upper extremities were normal. Second Admission. She was readmitted 5 months later after fouow-up x-ray films had shown that the rib graft on the left side had become detached, and that C-I had again become dislocated from C-2. Her mother had allegedly dropped her on two occasions. Physical examination on the second admission showed essentially no change from the previous examination except that the patient now had brisk, symmetrical deep-tendon reflexes in the lower extremities and sustained ankle clonus bilaterally. At reexploration, there was some flexibility of the rib graft on the left where it was attached to C-2 and C-3. The rib graft on the right was firm. The graft on the left was partially removed. The dislocation was again reduced; the midportion of the arch of C-I was removed for decompression, and C-1 was wired to C-2 to maintain reduction. Postoperatively, she was placed in a modified Minerva jacket. Again, when discharged, she had no spontaneous movements of the lower extremities and no return of sensation below T-I. She did well at home for 3 months and then vomited, aspirated, and died before medical assistance could be obtained. No autopsy was done. Case 2 This 33-month-old girl fell down a flight of stairs. She did not lose consciousness but complained of neck pain. When she was seen the next day by her local physician there were no apparent neurological or x-ray abnormalities. A soft cervical collar was applied. She continued to complain of neck pain, and cervical spine films 6 weeks after her accident showed subluxation of C-2 on C-3 (Fig. 1 upper left). She still had no neurological deficit. A posterior cervical fusion of CI-4 was done with rib grafts. Postoperative spine films showed satisfactory alignment of C-2 on C-3. She wore a four-poster brace for the next 4 months. She has been followed routinely for 13 years and at last examination had no limitation of neck movement and no neurological dysfunction. The fusion is solid (Fig. 1 upper right and lower left). Case 3 This 9-year-old boy was injured in an automobile accident and was unconscious when brought to the hospital. Cervical spine 2]2 J. Neurosurg. / Volume 45 / August, 1976

3 Cervical spine fusion in children FIG. 1. Case 2. Lateral x-ray film (upper left) shows subluxation of C-2 on C-3. Anteroposterior (upper right) and lateral (lower left and right) x-ray films show fusion of C1--4 at examination 13 years postoperatively. Note decreased anteroposterior diameter in fused vertebrae, but relatively normal vertebral height. films showed a fracture through the neural arch of C-2 and minimal anterior angulation of C-2 on C-3. He had bilateral abducens nerve palsies. A cervical collar was applied until he became conscious and flexion and extension films could be made. These showed only minimal motion between C-2 and C-3. He was discharged from the hospital with instructions to wear the cervical collar. X-ray films 4 months later showed a 5 mm anterior displacement of C-2 on C-3. He had no neurological deficit other than the bilateral abducens nerve palsies that had been present since his accident. Posterior C1-4 fusion with rib grafts was done, and he wore a four-poster brace for the next 4 months. Five years after his operation he has no neurological deficit and has a supple neck and stable fusion. Case 4 This 5-year-old boy was admitted to NCBH after he fell from a swing and complained of neck pain. He held his neck slightly flexed and his head tilted to the left. Cervical spine films revealed congenital absence of the odontoid, with subluxation of C-1 on C-2. J. Neurosurg. / Volume 45 / August, "13

4 J. M. McWhorter, et al. FIG. 2. Case 5. Lateral x-ray films show (left) congenital absence of odontoid, and (right) fusion of C1-3 5 years later. Posterior cervical C1-3 fusion was done with rib grafts, and he wore a four-poster brace for the next 3 months. On his last examination 7 years after operation he had a solid fusion and no measurable limitation of neck movement. Case 5 This 13-year-old girl complained of neck pain and occasional weakness and numbness in the left arm after strenuous activity. She had no history of significant trauma and no measurable neurological deficit. Cervical spine films showed congenital absence of the odontoid (Fig. 2 left) and hypermobility on flexion and extension. A posterior cervical C1-3 fusion was done with rib grafts, and she wore a four-poster brace for several months. Five years later she has a normal range of neck motion and a solid fusion (Fig. 2 right). Case 6 This 4-year-old boy suffered a severe head injury when struck by an automobile. He was comatose when he was admitted to the hospital. Cervical spine films revealed subluxation of C-1 on C-2, a fracture of the posterior lamina of C-l, and minimal subluxation of C-2 on C-3. Bilateral trephinations to remove bilateral subdural hygromas and a right subtemporal decompression were performed, and the cervical spine was stabilized with Crutchfield-tong traction. The patient's level of consciousness improved markedly over the next few weeks, and a posterior cervical C1-3 fusion was then done with rib grafts. He recovered sufficiently to be discharged, and wore a four-poster brace for the next 3 months. Now, 12 years after injury, he has a remarkably supple, stable neck and normal neurological findings. Discussion In 1937, Cone and Turner 2 reported two cases of posterior cervical fusion with rib grafts in children. Each fusion was performed over three levels. One child had a fracture of the odontoid and the other a fracture of the anterior arch of the atlas. Both patients did well, but had some restriction of neck movement. In 1967, Hamblen a reported using fusion from C-7 to the occiput to treat a 5-year-old child who had multiple congenital anomalies of the upper cervical vertebrae. The operation was a modification of that reported by Cone and Turner. 2 Cervical spine films 4 years later showed that the upper end of the graft had fractured. Hamblen believed the fracture was due to rapid growth in the anterior part of the child's spine which outpaced the fixed graft. The child's average range of cervical movement was only 10 ~ to 20 ~ of flexion and extension, 10 ~ of lateral flexion, and 10 ~ to 20 ~ of rotation. 2]4 J. Neurosurg. / Volume 45 / August, 1976

5 Cervical spine fusion in children In 1970, Roy and Gibson 8 reported a series of children who had undergone cervical fusion for instability of the cervical spine due to trauma, congenital malformation, or acquired disease. The fusion was done posteriorly with iliac crest grafts. Thirteen children, ranging in age from 2 to 15 years were so treated over a 10-year period. Roy and Gibson believed that a one-level bone fusion should be done whenever possible, because it preserved the greatest range of neck movement. However, one of their six one-level posterior fusions resulted in nonunion and had to be revised. The results in the six children in whom we have done a multiple-level posterior cervical fusion with rib grafts have been satisfactory. Four children had sustained cervical spine injuries in accidents, and two had congenital absence of the odontoid. Four patients had three-level fusions (C1-3) and two had fourlevel fusions (C1-4). Follow-up periods ranged from 3 months (death from unrelated cause) to 13 years (average 7.1 years), and the five living patients are still being followed. All are doing well and have the significant common finding of a remarkably supple, stable neck. After a long period of immobilization, some mild restriction of neck motion may be apparent, but this restriction appears to be only transient. Acrylic fixation as reported by Kelly, et al., 4 has been used with increasing frequency in adults in the treatment of atlantoaxial dislocations and instability of lower levels of the cervical spine. To date, such use of acrylics in children has not been reported. Theoretically, acrylics such as methyl methacrylate do not appear to be ideal substances for use in a growing area. They are inert, they stimulate no new bone formation, and they act only as a splint for the unstable vertebrae. Grafted bone, on the other hand, acts as both a stimulus to and a matrix for the formation ot new bone. References 1. Alexander E Jr, Forsyth HF, Davis CH Jr, et al: Dislocation of the atlas on the axis. The value of early fusion of C1, C2, and C3. J Neurosurg 15: , Cone W, Turner WG: The treatment of fracture-dislocations of the cervical vertebrae by skeletal traction and fusion. J Bone Joint Surg 19: , Hamblen DL: Occipito-cervical fusion. Indications, technique and results. J Bone Joint Surg 49B:33-45, Kelly DL Jr, Alexander E Jr, Davis CH Jr, et al: Acrylic fixation of atlanto-axial dislocations. Technical note. J Neurosurg 36: , Matson DD: Neurosurgery of Infancy and Childhood, ed 2. Springfield, Ill: Charles C Thomas, 1969, pp Roy L, Gibson DA: Cervical spine fusions in children. Clin Orthop 73: , 1970 Address reprint requests to: Joe M. McWhorter, M.D., Section on Neurosurgery, Bowman Gray School of Medicine, Winston-Salem, North Carolina J. Neurosurg. / Volume 45 / August,

Common fracture & dislocation of the cervical spine. Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University

$Common fracture & dislocation of the cervical spine. Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University$ Common fracture & dislocation of the cervical spine Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University Objective Anatomy Mechanism and type of injury PE.and radiographic evaluation