Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
J Neurosurg Spine. 2012 Nov;17(5):397-409. doi: 10.3171/2012.8.SPINE12770. Epub 2012 Sep 21.
The most common cause of cervical spine arthrodesis in the pediatric population is instability related to congenital or traumatic pathology. Instrumenting the cervical spine can be challenging given smaller anatomical structures, less ossified bone, and future growth potential and development. Studies in adult patients have suggested that using screw constructs results in improved outcomes with lower rates of instrumentation failure. However, the pediatric literature is limited to small retrospective series. Based on a review of the literature and their own patient series, the authors report that instrumenting the pediatric cervical spine with screw constructs may be safer and more effective than using wiring techniques.
The authors reviewed the existing pediatric cervical spine arthrodesis literature and contributed 31 of their own cases from September 1, 2007, to January 1, 2011. They reviewed 204 abstracts from January 1, 1966, to December 31, 2010, and 80 manuscripts with 883 total patients were included in the review. They recorded demographic, radiographic, and outcomes data-as well as surgical details-with a focus on fusion rates and complications. Patients were then grouped into categories based upon the procedure performed: 1) patients who underwent fusions bridging the occipitocervical junction and 2) patients who underwent fusion of the cervical spine that did not include the occiput, thus including atlantoaxial and subaxial fusions. Patients were further subdivided according to the type of instrumentation used-some had posterior cervical fusion with wiring (with or without rod implantation); others had posterior cervical fusion with screws.
The entire series comprised 914 patients with a mean age of 8.30 years. Congenital abnormalities were encountered most often (in 55% of cases), and patients had a mean follow-up of 32.5 months. From the entire cohort, 242 patients (26%) experienced postsurgical complications, and 50 patients (5%) had multiple complications. The overall fusion rate was 94.4%. For occipitocervical fusions (N = 285), both screw and wiring groups had very high fusion rates (99% and 95%, respectively, p = 0.08). However, wiring was associated with a higher complication rate. From a sample of 252 patients, 14% of those treated with screw instrumentation had complications, compared with 50% of patients treated with wiring (p < 0.05). In cervical fusions not involving the occipitocervical junction (N = 181), screw constructs had a 99% fusion rate, whereas wire instrumentation only had an 83% fusion rate (p < 0.05). Similarly, patients who underwent screw fixation had a lower complication profile (15%) when compared with those treated with wiring constructs (54%, p < 0.05).
The results of this study are limited by variations in construct design, use of orthoses, follow-up duration, and newer adjuvant products promoting fusions. However, a literature review and the authors' own series of pediatric cases suggest that instrumentation of the cervical spine in children may be safer and more efficacious using screw constructs rather than wiring techniques.
在儿科人群中，颈椎融合术最常见的原因是与先天性或创伤性病变相关的不稳定。由于解剖结构较小、骨化程度较低以及未来的生长潜力和发育，对颈椎进行器械操作具有挑战性。在成人患者中的研究表明，使用螺钉结构可改善结果并降低器械失效的发生率。但是，儿科文献仅限于小型回顾性系列研究。基于对文献的回顾和他们自己的患者系列研究，作者报告称，使用螺钉结构对儿科颈椎进行器械操作可能比使用布线技术更安全、更有效。
作者回顾了现有的儿科颈椎融合术文献，并贡献了他们自己的 31 例病例，时间为 2007 年 9 月 1 日至 2011 年 1 月 1 日。他们回顾了 1966 年 1 月 1 日至 2010 年 12 月 31 日的 204 篇摘要，并纳入了 80 篇论文和 883 名患者进行综述。他们记录了人口统计学、影像学和结果数据，以及手术细节，重点关注融合率和并发症。然后，根据所进行的手术将患者分为几类：1）进行融合术以跨越枕颈交界区的患者；2）进行颈椎融合术但不包括枕骨的患者，因此包括寰枢椎和颈段下融合术。根据使用的器械类型，患者进一步细分，一些患者进行了后路颈椎融合术，采用布线（有或无棒植入）；另一些患者则进行了后路颈椎融合术，使用螺钉。
整个系列包括 914 名患者，平均年龄为 8.30 岁。最常见的是先天性异常（占 55%），患者的平均随访时间为 32.5 个月。在整个队列中，242 名患者（26%）经历了术后并发症，50 名患者（5%）有多种并发症。总体融合率为 94.4%。对于枕颈融合术（N=285），螺钉组和布线组的融合率均非常高（分别为 99%和 95%，p=0.08）。然而，布线与更高的并发症发生率相关。在 252 名患者的样本中，接受螺钉器械治疗的患者中有 14%发生并发症，而接受布线治疗的患者中有 50%（p<0.05）。在不涉及枕颈交界区的颈椎融合术（N=181）中，螺钉结构的融合率为 99%，而布线器械的融合率仅为 83%（p<0.05）。同样，接受螺钉固定的患者并发症发生率较低（15%），而接受布线器械治疗的患者并发症发生率较高（54%，p<0.05）。
本研究结果受到器械设计、支具使用、随访时间以及促进融合的新型辅助产品的差异的限制。然而，文献综述和作者自己的儿科病例系列研究表明，与使用布线技术相比，使用螺钉结构对儿童颈椎进行器械操作可能更安全、更有效。
