History of Management of Cervical Spine Trauma in Children

Understanding of Disease

The ability to operate on cervical spine injury is a relatively recent development.14Landmarks in the evolution of cervical spinal surgery include:

• Hippocrates (460-370 BC): People in ancient times recognized the dire prognostic significance of spinal column trauma. Hippocrates described the paralysis that resulted from vertebral column fracture (31).
• Galen of Pergamon (129-210 AD): Galen performed experimental sectioning of the spinal cord at various levels and documented the level-dependent neurological deficits (6). These included the observation that respiratory muscle function was impaired by high cervical spinal cord lesions but not lower ones.
• Giovanni Morgagni (1682-1771 AD): Anatomical knowledge flourished in the Renaissance period. Morgagni provided further evidence to indicate that pressure on the spinal cord resulted in lower limb paralysis (6).
• Nineteenth-century spinal surgery: With the advent of anesthesia and asepsis, surgical interventions to treat spinal disease became feasible. Early spinal surgery was limited to the lumbar spine (14).
• Charles Elsberg (1871-1948):Elsberg was one of the pioneers of modern spinal surgery. In 1913, he published the results of 60 laminectomy procedures. He is credited with performing one of the earliest surgeries for cervical disk disease through a posterior approach in 1925 (6).
• CT/MRI:These investigations improved diagnostic sensitivity and spawned a technological revolution in spinal surgery.
• Smith and Robinson (1950s): These authors provided the first large series ofanterior cervical surgery in the treatment of cervical disk disease (34).
• Spinal instrumentation: Early techniques to stabilize the cervical spine were limited to wiring constructs. The past 20 years have seen a massive growth in more complex spinal instrumentation techniques, including lateral mass screws, pedicle screws, and artificial disks.
• Pediatric cervical instrumentation: Instrumentation techniques developed for use in adults have been modified and adapted for use in children. The past 10 years have seen the publication of several series reporting the use of instrumented fixation for cervical injury in children (49, 51, 52).

Technological Development

A number of technological advances have improved the evaluation and management of pediatric cervical spine trauma.

• Halo-vest immobilization: Many cervical spine injuries in children can be managed by immobilization without recourse to open surgery. Cervical collars can be difficult to fit in infants and young children, and compliance is poor. Halo-vests afford more rigid immobilization and are available in several pediatric sizes.
• Advances in imaging: 3-D CT provides high-definition imaging of vertebral injuries. These can be incorporated into neuronavigational platforms to aid placement of instrumentation.
• Intraoperative CT scanning: Portable CT scanning units for intraoperative use now facilitate real-time multiplanar imaging to optimize anatomical visualization and instrumentation placement.

Surgical Technique

Many of the technological advances in spine surgery that were developed in the field of adult spine surgery are being adapted and applied to children.

• Sublaminar cables: Sublaminar wires are still occasionally required to secure bone graft or rods to the posterior spinal elements.Flexible cables that are easier and safer to place have replaced stiff wires.
• Spinal instrumentation: Occipital plates and posterior screw fixation are increasingly used in pediatric cervical spine surgery for trauma and deformity (21). Although there are obvious anatomical constraints in terms of size, these techniques have been shown to be safe and more effective in achieving fusion than traditional methods (22).
• Intraoperative neurophysiological monitoring: Spinal cord monitoring is now an established adjunct to spine surgery in children.