Menezes Arnold H
Department of Neurosurgery, University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
J Neurosurg Pediatr. 2012 Jun;9(6):573-85. doi: 10.3171/2012.2.PEDS11371.
The surgical management of craniovertebral junction (CVJ) instability in pediatric patients presents unique challenges. As compared with the adult patient, the anatomical variations of the CVJ in the pediatric patient are significant, complicate the approach, and limit the use of internal fixation. Diminutive osseous and ligamentous structures and syndromic craniovertebral abnormalities complicate the issue. Advances in imaging analysis and instrumentation have improved the armamentarium for managing the pediatric patient who requires craniocervical stabilization. In this paper, the author's experience of performing more than 850 pediatric CVJ fusions is reviewed. This work includes the indications for atlantoaxial arthrodesis and occipitocervical fusion. Early atlantoaxial fusions were performed using interlaminar rib graft fusion, and more recently using either transarticular screw fixation in the older patient, or lateral mass screws at C-1 and rod fixation with either C-2 pars interarticular screw fixation or pedicle screw fixation. A C-2 translaminar screw fixation is also described. Occipitocervical fusions are performed with rib grafts in patients younger than 6 years of age. Subsequently, above that age, contoured loop fixation was performed, and in the past 8-10 years, screw and rod fixation was used. Abnormal spine growth was not observed in children who underwent craniocervical stabilization below the age of 5 years (clearly the bone grew with the patient). However, no deleterious effects were noted in the children treated with rigid instrumentation. The success rate for bone fusion alone was 98%. The author's success rate with rigid instrumentation is nearly 100%. A detailed review of the technique of fusion is presented, as well as the indications and means of avoidance of complications, their prevention, and management.
小儿患者颅颈交界区（CVJ）不稳的外科治疗面临独特挑战。与成年患者相比，小儿患者CVJ的解剖变异显著，使手术入路复杂化，并限制了内固定的使用。微小的骨与韧带结构以及综合征性颅颈异常使问题更加复杂。影像分析和器械的进展改善了治疗需要颅颈稳定的小儿患者的手段。本文回顾了作者进行850余例小儿CVJ融合手术的经验。这项工作包括寰枢椎融合术和枕颈融合术的适应证。早期寰枢椎融合术采用层间肋骨移植融合，最近在年龄较大的患者中采用经关节螺钉固定，或在C-1处采用侧块螺钉并结合C-2关节突间螺钉固定或椎弓根螺钉固定进行棒固定。还描述了C-2经椎板螺钉固定。6岁以下患者的枕颈融合术采用肋骨移植。此后，在该年龄以上，采用轮廓化环固定，在过去8至10年中，采用螺钉和棒固定。在5岁以下接受颅颈稳定手术的儿童中未观察到脊柱生长异常（显然骨骼随患者生长）。然而，在接受刚性器械治疗的儿童中未发现有害影响。单纯骨融合的成功率为98%。作者使用刚性器械的成功率接近100%。本文详细介绍了融合技术，以及并发症的适应证、避免方法、预防和处理。
