- Brainstem or spinal cord injury: Although very uncommon, it is possible to cause brainstem or spinal cord injury during one of several phases of surgery. These include turning the patient to the prone position, opening and bony removal, and placement of instrumentation.
- Instrumentation failure: Instrumentation failure depends on several factors, including the anatomical suitability of the patient’s bone, the quality of the patient’s bone, and the actual site of site of screw or instrumentation placement. These factors may be mitigated in large part with careful preoperative planning.
- Fusion failure: Failure of the arthrodesis requiring reoperation occurs infrequently when proper technique of instrumentation and fusion is followed. Reported rates of successful arthrodesis in C1-2 instrumented fusion in children are close to 100% (9). Fusion failure may be a result of several factors, including improper or inadequate instrumentation, improper graft preparation or placement, or failure to secure the graft properly. It is unclear whether fusion adjuncts such as demineralized bone matrix or bone morphogenetic protein actually contribute to higher fusion rates, although they may speed up the rate of fusion in selected patients.
- Wound complications: Care must be taken during placement of the instrumentation and fusion so that the construct does not place pressure on the skin, scalp or wound edges.
- Halo complications: If the patient is placed in a halo orthosis either before or after surgery, pin and vest care must be routinely performed. Pin site infections are common and are usually managed by removing the infected pin and placing another one in an adjacent pin site. If the pins are tightened beyond the initial adjustment, they may break through the calvarium and cause parenchymal brain injury, including abscesses or hematomas.
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