Article
Technical note: Dorsal reposition technique of cranio-cervical pathologies with ventral compression of myelon and brainstem in children
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Authors
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Andreas Röhrig
- Asklepios Kinderklinik Sankt Augustin
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Sergey Persits
- Asklepios Kinderklinik Sankt Augustin
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Martina Messing-Jünger
- Asklepios Kinderklinik Sankt Augustin
| Published: | June 2, 2015 |
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Outline
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Objective: Indications for cranio-cervical instrumentation are rare. This surgery is performed only in selected cases with instability. Most of the technical strategies decribe posterior approach for the spondylodesis and a additional transoral approach to reduce the ventral brainstem compression. A special dorsal reposition technique can be used to ventrally decompress the upper brainstem. A series of 12 children (mean 10-year-old, range 3-17 y) with CVJ instability and pathological clivo-vertebral angle (less than 135°) was investigated retrospectively. Beside diagnostic findings (pre- and postoperative x-ray, CT and MRI) the opertive reposition and fixation technique is described.
Method: All patients were positioned in a mayfield clamp in a straight a-p-position. After placing the pedicular screws in C2 and the occipital plate, rods will be positioned into the screws and fixed in distance to the occipital plate. The rods will be pressed slowly towards the plate which moves the tip of the dens axis ventrally. After correction of the clivo-vertebral angle the dens will be pulled out from foramen magnum by distraction of the screws and the plate. For bony fusion iliac crest material was used.
Results: A ventral brainstem compression was reduced in all cases sufficient. Preoperative halo extension was performed in 5 children. There was no difference of the distance between the tip of the dens and the foramen magnum in both groups (halo-traction versus non halo-traction; 2.25 versus 2.3 mm) and no significant improvement of the clivo-vertebral angle. The mean diameter of the spinal canal at CVJ before surgery was 15,9 mm, after surgery 28.7 mm. The mean clivo-vertebral angle before surgery was 109° (79° - 133°), after 131° (104° - 145°). The spinal canal width was significantly reduced in syndromal patients (9.5 mm versus 22.3 mm).
Complications: 1 vertebral artery occlusion, 1 secondary instrumentation insufficiency (Down syndrome). Both without neurological sequelae. All patients demonstrated an improved and stable neurologicals status during follow-up (1-7 years).
Conclusions: The dorsal reposition is safe and very sufficient. 50% of the children had a syndromal background (Klippel-Feil-, Down- and Ehlers-Danlos syndrom). Preoperative extension was not beneficial.
