Elsevier

World Neurosurgery

Volume 140, August 2020, Pages e81-e86
World Neurosurgery

Original Article
Atlanto-Occipital Transarticular Screw Fixation for the Treatment of Traumatic Occipitocervical Instability in the Pediatric Population

https://doi.org/10.1016/j.wneu.2020.04.129Get rights and content

Background

Atlanto-occipital transarticular screw fixation (AOTSF) has rarely been reported for fixation of the craniovertebral junction (CVJ).

Methods

A retrospective chart review of all pediatric patients (less than 18 years of age) with an attempt of AOTSF for fixation of traumatic CVJ instability was conducted.

Results

A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years) who suffered from acute traumatic CVJ instability managed during 2007–2018 underwent an attempted AOTSF. In 2 patients, this method was technically successful. In the other 2 instances, we were not able to engage the screw into the occipital condyle. These were converted to standard occipital plate, rod, and screw fixation. All were placed in a halo subsequently for a minimum of 3 months. Three patients were fused at last follow-up (range, 17–48 months). One patient after successful AOTSF did not fuse. There were no surgical complications or revision procedures.

Conclusions

AOTSF was feasible in half of pediatric patients suffering from traumatic CVJ instability. Therefore, intraoperative salvage options and strategies should be on hand readily. In the pediatric population, where bony anatomy may pose challenges to fixation, this technique may offer a viable first-line option in selected cases, despite the overall modest success rate.

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.

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