Original ArticleAtlanto-Occipital Transarticular Screw Fixation for the Treatment of Traumatic Occipitocervical Instability in the Pediatric Population
Introduction
Injuries to the cervical spine in the pediatric population often involve the craniovertebral junction (CVJ).1, 2, 3 These injuries are potentially lethal and may cause severe neurologic deficits.4,5 Fixation of the traumatically injured pediatric CVJ is technically difficult and traditionally has relied on wires, cables, and sutures.6, 7, 8, 9, 10, 11 If bony anatomy allows, fixation using screws, rods, and plates have been applied in this setting.12, 13, 14, 15, 16, 17, 18 In 2001, Grob19 introduced the first successful atlanto-occipital transarticular screw fixation (AOTSF) in an 11-year-old patient after trauma to stabilize the CVJ. Since then, 2 more cases have been reported.20,21 Here we report on a small case series of pediatric patients that suffered from traumatic CVJ instability where AOTSF was attempted.
Section snippets
Methods
A retrospective chart review was conducted to identify all pediatric patients (less than 18 years of age) with traumatic CVJ instability from 2007 to 2018 who underwent surgery for occipitocervical fusion. Furthermore, we identified all patients that had an attempted AOTSF at Valleywise Health Medical Center, Phoenix, Arizona.
This study was exempt from institutional review board approval.
Results
During the study period, 7 pediatric patients underwent occipitocervical fusion for traumatic instability. Of these, a total of 3 patients (9, 11, 17 years of age; mean age, 12.3 years) underwent a standard plate/rod/screw fixation. A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years; mean age, 4 years) with traumatic CVJ instability were identified during the study period who underwent an attempted AOTSF. All suffered from motor vehicle accidents. Only 1 patient was
Case 1
An 8-year-old girl presented with traumatic CVJ instability after a motor vehicle accident. The patient was comatose and found to have a high spinal cord injury at C1 and associated anoxic brain injury. Despite the dismal neurologic prognosis, the family desired surgical care. Because of associated occipital scalp erosion, the goal was to avoid a suboccipital plate. Therefore, we proceeded with AOTSF, which was successful, and follow-up imaging demonstrated bony fusion. The patient succumbed
Discussion
Over the last 20 years, interest has emerged for screw fixation involving the occipital condyle to stabilize the CVJ.19, 20, 21, 22, 23, 24, 25, 26, 27, 28 Numerous anatomic and radiographic studies have emerged analyzing suitable trajectories for screw placement.29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 Two distinct posterior techniques have emerged. One uses a direct screw placement into the occipital condyle, which is then connected via a rod to screws placed in standard fashion into
Conclusions
AOTSF is a challenging technique that can be applied to fixate the CVJ successfully and effectively in conjunction with halo immobilization in half the attempted cases in the pediatric population.
We think AOTSF has an indication for upfront application in situations that mandate posterior fossa surgery associated with occipital scalp trauma, and in young patients where a standard rigid screw fixation approach may be hampered by small bone size.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.