Neonatal C1 TO C2 osteomyelitis leading to instability and neurological decline: novel treatment with occiput-C1-C2 fusion and occiput to thorax growing rods. A case report.

BACKGROUND: Vertebral osteomyelitis of the upper cervical spine requiring surgical treatment in children is rare. Surgical treatment of the immature spine is commonly associated with certain risks and complications. We describe a unique treatment approach for a young child that required emergent stabilization of the upper cervical spine due to progressive instability caused by osteomyelitis. METHODS: A 3-month-old infant with neurological decline from progressive instability of the occiput C1 and C2 was admitted for surgical treatment after failed bracing. The patient had reduction and occiput to C2 posterior fusion and segmental instrumentation, with nonsegmental instrumentation extending in the soft tissues from C2 to T4 with the intent of providing stabilization without fusion and permitting further growth. RESULTS: The implants were removed 1 year after the original procedure. At 2 years following implant removal, he continued to have mild global developmental delay but was progressing well and was able to navigate independently with a posterior walker, using AFOs for support. Subaxial cervical motion and x-ray appearance were normal. CONCLUSIONS: The technique used here to overcome the difficulty of providing secure immobilization of the craniocervical junction while not creating inadvertent fusion of the subaxial cervical spine may have application in other clinical situations. LEVEL OF EVIDENCE: Level V.

Efficacy of nonfusion treatment for subacute and chronic atlanto-axial rotatory fixation in children.

BACKGROUND: Historical guidelines suggest limited efficacy for nonfusion treatment of chronic atlanto-axial rotatory subluxation/fixation (AARF). Surgical fusion has potential side effects; therefore, it is important to understand the role for nonfusion treatment of chronic AARF. This case series examines the success rate of nonfusion treatment. METHODS: A key word search was used to identify all patients with AARF with delayed presentation of ≥ 4 weeks. Fifteen patients met study inclusion criteria and had adequate clinical information for review. Data collected included age, sex, delay in presentation, mechanism of injury, severity of subluxation (Fielding classification), treatment, follow-up, and clinical information at latest follow-up. RESULTS: There were 11 girls and 3 boys with an average age of 7.2 years (range, 1.5 to 12 years). Initial treatment of 3 patients included fusion. Eleven patients were initially treated without fusion. Eight of these 11 patients were successfully reduced with either halter traction, halo gravity traction, and noninvasive halo or halo vest, and reduction was maintained without fusion (73%) at 10.3 years follow-up. Three patients (27%) experienced recurrence of AARF at an average time of 2 weeks (range, 0 to 4 wk) and were treated with fusion. Average delay in presentation for all patients was 18 weeks (range, 4 to 92 wk), whereas it was 6 weeks and 9.3 weeks in those successfully treated without fusion and in those who failed nonfusion treatment, respectively. Age, delay in presentation, and underlying diagnosis were similar for fusion and nonfusion groups. CONCLUSIONS: Although AARF may recur after a trial of reduction and nonfusion treatment, pediatric patients with delayed presentation (>1 month) of AARF may be treated with an initial trial of nonfusion treatment. Parents should be counseled about the risk of recurrence and possible need for ultimate fusion. LEVEL OF EVIDENCE: Level III, therapeutic retrospective comparative study.