The Operation for Cervical Spine Trauma in Children

Patient Positioning

• Attention to standard precautions: For all patients, careful pressure point protection is critical. Younger patients, particularly preteens and younger, are more susceptible to pressure sores than adults. Special care must be taken to prevent venous restriction around the face and chin, which can be caused by some open-face pillows designed for prone positioning, as this may lead to skin breakdown and sloughing.
• Pin fixation for head: This is preferred to avoid pressure injuries and also to aid in intraoperative mechanical stability. Head fixation with pins is preferable for cervical fusions when it can be used.
• Modify for young age: Pediatric Mayfield pins or specialized padded head holders are required for infants and young children.
• Neck in neutral position: Care must be taken to ensure that cervical spine alignment is neutral and physiologically optimal, particularly for long constructs or when the occiput will be included. Flexion, in particular, should be avoided as this can result in spinal pain as the patient adopts a lordotic posture to compensate. Fixation in a flexed position can also compromise the airway.

Surgical Approach

Anterior

• Transverse or oblique skin incision: A transverse neck incision will suffice for single-level access. For multiple-level access, an oblique incision along the anterior border of the sternomastoid will improve exposure.
• Retract carotid and jugular laterally: The plane between the vascular structures, carotid sheath (lateral) and visceral structures, esophagus/trachea (medial) is developed. The paired longus coli muscles are elevated from the anterior vertebral body and used to “seat” the retraction system.
• Discectomy and graft for fusion: Anterior fusion is achieved by removing the intervertebral disk to expose the adjacent end plates. The cartilage of the end plate should be removed, using curettes or a drill; this exposes the cancellous bone to facilitate incorporation of a bone graft. An autologous bone graft (iliac crest or rib) is placed into the intervertebral space. The graft is then secured in place using a cervical plate with screws into the adjacent vertebral bodies.

Posterior

• Midline skin incision: A midline incision is used.
• Avascular separation of neck muscles: With cutting diathermy, the posterior neck muscles are separated in the midline, and a subperiosteal muscle reflection is performed to expose the laminae and facet joints.
• Identify facet joint: Clear identification of the facet joint is important to visualize landmarks for screw placement.

Intervention

Although spine surgery in children uses many of the same techniques as in adults, the spine is smaller and this difference must be considered in planning intervention

• Avoidance of growth centers: The small anatomy and variable levels of ossification necessitate a thorough knowledge of fixation point options. Possessing a large “bag of tricks” improves the surgeon’s ability to build a solid construct.
• Instrumentation, wires and screws are avoided in infants. 
• Bone with Wiring is used in young children.
• Older children easier: Larger bone size and more mature bone improves the pull-out strength of screws. Screw, hook, sublaminar cables, and rod constructs may have to be used in younger children.

Atlanto-occipital dislocations

• Highly unstable, requiring internal fixation: Atlanto-occipital dislocations are unstable and require internal fixation and fusion.
• Occipito-cervical instrumented fixation: The exact construct will depend on the complete constellation of injuries. As a minimum, the occipito-atlantal joint must be stabilized. A plate is secured to the occiput and then connected via rods to C2 pedicle screws or cervical lateral mass screws. In young children, bone size and quality may preclude cervical screw placement. Alternative distal fixation options include sublaminar cables or translaminar screws.

“Atlanto-axial dislocation

• Unstable, usually requiring internal fixation: Some unstable fractures may heal in hard collar, but most of these injuries require internal surgical stabilization.
• C1-C2 fusion (instrumented): As long as there is no obvious involvement of the occipito-atlantal joint, a single-level fixation at C1-C2 will suffice. Options include C1-C2 transarticular screws or the Goel-Harms technique.
• C1-C2 fusion (cable/graft): In young children, a Gallie/Brooks-type fusion can be used comprising an interlaminar bone graft and sublaminar cables.

Atlanto-axial rotary subluxation

• Occasionally C1-C2 internal fixation: Occasionally, surgical fixation across the C1-C2 interspace may be required when external fixation does not maintain alignment. Any of the techniques for isolated C1-C2 fixation can be used. It is important to ensure adequate correction of any rotational deformity before attempted placement of C1 lateral mass screws to ensure optimal screw trajectory and avoid vertebral artery injury.

Jefferson fracture

• Many stable: Fractures that include disruption of the transverse ligament are unstable and require internal fixation.
• Internal fixation: If a trial of halo immobilization fails to result in bony union, then internal fixation is indicated. This can be achieved by any of the C1-C2 fixation techniques.

Odontoid fractures

• Type II – unstable: Type II odontoid fractures usually require fixation with a halo vest, odontoid screw fixation, or posterior C1-C2 fusion.
• Type III – variable stability: When an odontoid fracture is stable, it may be treated with halo immobilization or possibly a rigid collar. If unstable, its treatment requires halo immobilization, although some may be treated by fixation with an odontoid screw.

Hangman’s fracture

• Internal fixation when bracing fails: Immobilization is the initial management of choice unless there is significant anterior displacement of C2 on C3 (>3 mm) (26). Where conservative management (rigid collar, SOMI, Minerva, or halo orthotic) fails, then surgical fixation is required. There is no consensus on the most appropriate surgical technique. Options comprise anterior C2/C3 discectomy and fusion, posterior instrumented fixation, or a combination of these.

Teardrop fracture

• Halo for temporary immobilization: A halo vest may be useful for temporary immobilization.
• Internal fixation: Most of these fractures heal with immobilization for 4–6 weeks. If there is persisting instability or progressive deformity, surgery is indicated. This may require anterior discectomy and fusion, supplemented by plating if there is severe kyphosis. Posterior fusion can be used either alone or in addition to anterior fusion.

Cervical compression fractures

• Decompression: When the spine is compromised by extruded bone fragments, surgical decompression may be indicated. This may often be accomplished by anterior corpectomy, although adjunctive posterior fusion may also be needed.
• Fusion: An anterior or posterior fusion may be performed, or in some cases both.

Ligamentous Injury

• Internal fixation: This may sometimes be accomplished from a posterior approach, anterior approach, or a combination of the two depending on the injury when the spine is thought to be unstable.

Closure

• Standard multilayer: A multilayer closure is performed, with details depending on the surgery, but using an absorbable suture.
• Skin: For skin closure, absorbable sutures are preferred to staples by the author, particularly in very young patients. For smaller incisions and incisions in cosmetically sensitive areas, the author has found that subcuticular stitches using absorbable sutures are effective, particularly when combined with a glue-type dressing.