Skip to main content

Advertisement

SpringerLink
Log in

Complications and outcomes of posterior fusion in children with atlantoaxial instability

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Introduction

Atlantoaxial instability (AAI) is an uncommon disease in children. Surgical treatment of pediatric patients with AAI poses a challenge to spine surgeons because of the patients’ immature bone quality, extensive anatomical variability, and smaller osseous structures. In this study, the authors report complications and outcomes after posterior fusion in children with AAI.

Methods

The authors reviewed medical records of patients 13 years old and younger with AAI who underwent posterior fusion in the Nagoya Spine Group hospitals, a multicenter cooperative study group, from January 1995 to December 2007. We identified 11 patients who underwent posterior fusion, and analyzed their clinical outcomes and complications. To determine if vertical growth within the construct continued after posterior fusion, in three patients at 5 or more years following occipito-cervical (O-C) fusion, intervertebral disc heights and vertebral heights between the fused and non-fused levels were compared on the final follow-up.

Results

The initial surgeries were C1–C2 fusions in six patients and O-C fusion in five patients. Successful fusion ultimately occurred in all patients, however, the complication rate related to the operations was high (64%). Complications included neurologic deterioration, pedicle fracture with pedicle screw insertion, C1 posterior arch fracture with lateral mass screw insertion, perforation of the skull with a head pin placement, and fusion extension to adjacent vertebrae. Two patients required reoperation. The mean fixed and non-fixed intervertebral disc heights on the final follow-up were 2.6 and 5.3 mm, respectively, showing that the disc height of the fixed level was less than the non-fused level. Each vertebra lengthened similarly between fused and non-fused levels except for C2 which had a lower growth rate than the other vertebrae.

Conclusions

A high complication rate should be anticipated after posterior fusion in children with AAI. Careful consideration should be paid to pediatric patients with AAI treated by screw and/or rod systems. After posterior fusion in pediatric patients, each vertebra continued to grow, in contrast the disc height decreased between fused levels.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AAI:

Atlantoaxial instability

AARF:

Atlantoaxial rotatory fixation

AAS:

Atlantoaxial subluxation

References

  1. Doyle JS, Lauerman WC, Wood KB, Krause DR (1996) Complications and long-term outcome of upper cervical spine arthrodesis in patients with Down syndrome. Spine 21:1223–1231

    Article  PubMed  CAS  Google Scholar 

  2. Segal LS, Drummond DS, Zanotti RM, Ecker ML, Mubarak SJ (1991) Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome. J Bone Joint Surg Am 73:1547–1554

    PubMed  CAS  Google Scholar 

  3. Jeanneret B, Magerl F (1992) Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5:464–475

    Article  PubMed  CAS  Google Scholar 

  4. Goel A, Laheri V (1994) Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129:47–53

    Article  CAS  Google Scholar 

  5. Harms J, Melcher RP (2001) Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 26:2467–2471

    Article  Google Scholar 

  6. Wright NM (2004) Posterior C2 fixation using bilateral, crossing C2 laminar screws: case series and technical note. J Spinal Disord Tech 17:158–162

    Article  PubMed  Google Scholar 

  7. Belen D, Simsek S, Yigitkanli K, Bavbek M (2006) Internal reduction established by occiput-C2 pedicle polyaxial screw stabilization in pediatric atlantoaxial rotatory fixation. Pediatr Neurosurg 42:328–332. doi:10.1159/000094073

    Article  PubMed  Google Scholar 

  8. Brockmeyer DL, York JE, Apfelbaum RI (2000) Anatomical suitability of C1–2 transarticular screw placement in pediatric patients. J Neurosurg 92:7–11

    Article  PubMed  CAS  Google Scholar 

  9. Chamoun RB, Whitehead WE, Curry DJ, Luerssen TG, Jea A (2009) Computed tomography morphometric analysis for C-1 lateral mass screw placement in children. Clinical article. J Neurosurg Pediatr 3:20–23. doi:10.3171/2008.10.PEDS08224

    Article  PubMed  Google Scholar 

  10. Desai R, Stevenson CB, Crawford AH, Durrani AA, Mangano FT (2010) C-1 lateral mass screw fixation in children with atlantoaxial instability: case series and technical report. J Spinal Disord Tech 23:474–479. doi:10.1097/BSD.0b013e3181bf9f24

    Article  PubMed  Google Scholar 

  11. Haque A, Price AV, Sklar FH, Swift DM, Weprin BE, Sacco DJ (2009) Screw fixation of the upper cervical spine in the pediatric population. Clinical article. J Neurosurg Pediatr 3:529–533. doi:10.3171/2009.2.PEDS08149

    Article  Google Scholar 

  12. Hedequist D, Proctor M (2009) Screw fixation to C2 in children: a case series and technical report. J Pediatr Orthop 29:21–25. doi:10.1097/BPO.0b013e3181924367

    Article  PubMed  Google Scholar 

  13. Heuer GG, Hardesty DA, Bhowmick DA, Bailey R, Magge SN, Storm PB (2009) Treatment of pediatric atlantoaxial instability with traditional and modified Goel-Harms fusion constructs. Eur Spine J 18:884–892. doi:10.1007/s00586-009-0969-x

    Article  PubMed  Google Scholar 

  14. Jea A, Taylor MD, Dirks PB, Kulkarni AV, Rutka JT, Drake JM (2007) Incorporation of C-1 lateral mass screws in occipitocervical and atlantoaxial fusions for children 8 years of age or younger. Technical note. J Neurosurg 107:178–183. doi:10.3171/PED-07/08/178

    Google Scholar 

  15. Leonard JR, Wright NM (2006) Pediatric atlantoaxial fixation with bilateral, crossing C-2 translaminar screws. Technical note. J Neurosurg 104:59–63. doi:10.3171/ped.2006.104.1.59

    PubMed  Google Scholar 

  16. Reilly CW, Choit RL (2006) Transarticular screws in the management of C1–C2 instability in children. J Pediatr Orthop 26:582–588. doi:10.1097/01.bpo.0000230337.26652.55

    Article  PubMed  Google Scholar 

  17. Wang J, Vokshoor A, Kim S, Elton S, Kosnik E, Bartkowski H (1999) Pediatric atlantoaxial instability: management with screw fixation. Pediatr Neurosurg 30:70–78 (pne30070[pii])

    Article  PubMed  CAS  Google Scholar 

  18. Nakagawa T, Yone K, Sakou T, Yanase M (1997) Occipitocervical fusion with C1 laminectomy in children. Spine 22:1209–1214

    Article  PubMed  CAS  Google Scholar 

  19. Parisini P, Di Silvestre M, Greggi T, Bianchi G (2003) C1-C2 posterior fusion in growing patients: long-term follow-up. Spine 28:566–572. doi:10.1097/01.BRS.0000049961.22749.49 (discussion 572)

    PubMed  Google Scholar 

  20. Burke SW, French HG, Roberts JM, Johnston CE 2nd, Whitecloud TS 3rd, Edmunds JO Jr (1985) Chronic atlanto-axial instability in Down syndrome. J Bone Joint Surg Am 67:1356–1360

    PubMed  CAS  Google Scholar 

  21. Juhl M, Seerup KK (1983) Os odontoideum. A cause of atlanto-axial instability. Acta Orthop Scand 54:113–118

    Article  PubMed  CAS  Google Scholar 

  22. Tredwell SJ, Newman DE, Lockitch G (1990) Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 10:602–606

    Article  PubMed  CAS  Google Scholar 

  23. Uno K, Kataoka O, Shiba R (1996) Occipitoatlantal and occipitoaxial hypermobility in Down syndrome. Spine 21:1430–1434

    Article  PubMed  CAS  Google Scholar 

  24. Brooks AL, Jenkins EB (1978) Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg Am 60:279–284

    PubMed  CAS  Google Scholar 

  25. Dickman CA, Sonntag VK, Papadopoulos SM, Hadley MN (1991) The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74:190–198. doi:10.3171/jns.1991.74.2.0190

    Article  PubMed  CAS  Google Scholar 

  26. Gallie WE (1937) Skeletal traction in the treatment of fractures and dislocations of the cervical spine. Ann Surg 106:770–776

    Article  PubMed  CAS  Google Scholar 

  27. Aryan HE, Newman CB, Nottmeier EW, Acosta FL Jr, Wang VY, Ames CP (2008) Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques. J Neurosurg Spine 8:222–229. doi:10.3171/SPI/2008/8/3/222

    Article  PubMed  Google Scholar 

  28. Hott JS, Lynch JJ, Chamberlain RH, Sonntag VK, Crawford NR (2005) Biomechanical comparison of C1–2 posterior fixation techniques. J Neurosurg Spine 2:175–181. doi:10.3171/spi.2005.2.2.0175

    Article  PubMed  Google Scholar 

  29. Yoshida G, Kamiya M, Yoshihara H, Kanemura T, Kato F, Yukawa Y, Ito K, Matsuyama Y, Sakai Y (2010) Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws. J Neurosurg Spine 13:443–450. doi:10.3171/2010.4.SPINE09662

    Article  PubMed  Google Scholar 

  30. Anderson RC, Kan P, Gluf WM, Brockmeyer DL (2006) Long-term maintenance of cervical alignment after occipitocervical and atlantoaxial screw fixation in young children. J Neurosurg 105:55–61. doi:10.3171/ped.2006.105.1.55

    PubMed  Google Scholar 

  31. Rodgers WB, Coran DL, Kharrazi FD, Hall JE, Emans JB (1997) Increasing lordosis of the occipitocervical junction after arthrodesis in young children: the occipitocervical crankshaft phenomenon. J Pediatr Orthop 17:762–765

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors are grateful to all the staff of Nagoya Spine Group for allowing them to study their patients and for their assistance with data collection.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 4668550, Japan

    Ryoji Tauchi, Shiro Imagama, Zenya Ito, Kei Ando, Kenichi Hirano, Akio Muramoto, Hiroki Matsui & Naoki Ishiguro

  2. Department of Orthopaedic Surgery, Chubu Rosai Hospital, Nagoya, Japan

    Fumihiko Kato & Yasutsugu Yukawa

  3. Department of Orthopaedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan

    Koji Sato

  4. Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan

    Tokumi Kanemura

  5. Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan

    Hisatake Yoshihara

  6. Department of Orthopaedic Surgery, Aichi Medical University, Aichi-gun, Japan

    Mitsuhiro Kamiya

  7. Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan

    Yukihiro Matsuyama

Authors
  1. Ryoji Tauchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shiro Imagama
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zenya Ito
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kei Ando
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kenichi Hirano
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Akio Muramoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hiroki Matsui
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Fumihiko Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Yasutsugu Yukawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Koji Sato
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Tokumi Kanemura
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Hisatake Yoshihara
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Mitsuhiro Kamiya
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Yukihiro Matsuyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Naoki Ishiguro
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ryoji Tauchi.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tauchi, R., Imagama, S., Ito, Z. et al. Complications and outcomes of posterior fusion in children with atlantoaxial instability. Eur Spine J 21, 1346–1352 (2012). https://doi.org/10.1007/s00586-011-2083-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-011-2083-0

Keywords

Search

Navigation