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J Neurosurg Pediatr. 2018 Jul;22(1):81-88. doi: 10.3171/2018.1.PEDS17551. Epub 2018 Apr 20.

Growth and alignment of the pediatric subaxial cervical spine following rigid instrumentation and fusion: a multicenter study of the Pediatric Craniocervical Society.

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1Department of Pediatric Neurosurgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York.
2Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida.
3Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.
4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.
5Department of Pediatric Neurosurgery, Yale School of Medicine, New Haven, Connecticut.
6Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, Indiana.
7Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado.
8Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
9Department of Neurological Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri.
10Department of Neurosurgery, Connecticut Children's Medical Center, Hartford, Connecticut.
11Department of Orthopedic Surgery, Shriners Hospitals for Children, Philadelphia, Pennsylvania.
12Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
13Division of Neurosurgery, Children's of Alabama, Birmingham, Alabama; and.
14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.


OBJECTIVE The long-term effects of surgical fusion on the growing subaxial cervical spine are largely unknown. Recent cross-sectional studies have demonstrated that there is continued growth of the cervical spine through the teenage years. The purpose of this multicenter study was to determine the effects of rigid instrumentation and fusion on the growing subaxial cervical spine by investigating vertical growth, cervical alignment, cervical curvature, and adjacent-segment instability over time. METHODS A total of 15 centers participated in this multi-institutional retrospective study. Cases involving children less than 16 years of age who underwent rigid instrumentation and fusion of the subaxial cervical spine (C-2 and T-1 inclusive) with at least 1 year of clinical and radiographic follow-up were investigated. Charts were reviewed for clinical data. Postoperative and most recent radiographs, CT, and MR images were used to measure vertical growth and assess alignment and stability. RESULTS Eighty-one patients were included in the study, with a mean follow-up of 33 months. Ninety-five percent of patients had complete clinical resolution or significant improvement in symptoms. Postoperative cervical kyphosis was seen in only 4 patients (5%), and none developed a swan-neck deformity, unintended adjacent-level fusion, or instability. Of patients with at least 2 years of follow-up, 62% demonstrated growth across the fusion construct. On average, vertical growth was 79% (4-level constructs), 83% (3-level constructs), or 100% (2-level constructs) of expected growth. When comparing the group with continued vertical growth to the one without growth, there were no statistically significant differences in terms of age, sex, underlying etiology, surgical approach, or number of levels fused. CONCLUSIONS Continued vertical growth of the subaxial spine occurs in nearly two-thirds of children after rigid instrumentation and fusion of the subaxial spine. Failure of continued vertical growth is not associated with the patient's age, sex, underlying etiology, number of levels fused, or surgical approach. Further studies are needed to understand this dichotomy and determine the long-term biomechanical effects of surgery on the growing pediatric cervical spine.


alignment; cervical; fusion; growth; stability; subaxial spine

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