Pediatric occipitocervical arthrodesis : A review of current options and early evaluation of rigid internal fixation techniques

Few reports exist on the options and effectiveness of craniocervical stabilization in the pediatric population compared with the adult literature. Traditional options in children include onlay grafting and semi-rigid occipitocervical wiring. Recently, reports on the use of rigid internal fixation devices such as occipitocervical plates and contoured loops have provided excellent results in adults, and their use has often obviated the need for external orthosis. The purpose of this article is to report our experience with both traditional and newer rigid internal fixation methods for occipitocervical fusion in children. During the past 4.5 years, 14 children (ages 4 months to 16 years) have undergone occipitocervical fusion. Indications for fusion included trauma (n = 4), congenital instability/stenosis (n = 6), postinfectious instability (n = 1) and basilar invagination (n = 3). Techniques using onlay grafting (n = 3) as well as rigid internal fixation using plates (n = 1) and contoured craniocervical titanium loops (n = 10) were used. Postoperative orthosis included halo vests (n = 7), minerva jackets (n = 3), sterno-occipital mandibular immobilizer (n = 1), and a cervical collar (n = 3). Long-term follow-up (range 13-58 months) was available for 13 of the 14 children. While each occipitocervical fusion in pediatric patients requires a customized treatment plan, we believe children older than 12 months of age should be considered candidates for rigid internal fixation methods. The rigidity afforded by this method may eliminate the need for rigid external orthotic support in selected individuals. In our experience, anatomic constraints in children less than 1 year old usually require fusion with more traditional onlay techniques. Long-term follow-up studies are still required to assess the effects of rigid internal fixation in the skeletally immature spine.