Treatment of Atlantoaxial Instability in Pediatric Patients

Scott Y. Rahimi, MD; E. Andrew Stevens, BS; David John Yeh, MD; Ann Marie Flannery, MD; Haroon Fiaz Choudhri, MD; and Mark R. Lee, MD, PHD.


Neurosurg Focus. 2003;15(6) 

In This Article

Abstract and Introduction

The atlantoaxial region has been extensively described as a spinal segment especially prone to injury in children. In this clinical review, the authors evaluate and summarize the management of 23 pediatric cases of atlantoaxial instability treated between March 1990 and October 2002. Four broad categories of atlantoaxial problems were observed— atlantoaxial rotatory subluxation in six patients, anterior–posterior atlantoaxial instability caused by ligamentous injury or congenital ligamentous laxity (10 patients), atlantoaxial fracture with or without dislocation (five patients), and atlantooccipital dislocation (two patients). Most cases (60.9%) were treated without surgical intervention, resulting in excellent outcomes; however, 21.7% of cases were treated with a cervical halo (mean patient age 72.6 months) alone for 3 months. Various techniques of surgical stabilization including transarticular screws with sublaminar wiring, transoral decompression with posterior plating, and laminectomy with Steinmann pin occipital–cervical fusion were used with good results. Both patients with atlantooccipital dislocation underwent immediate Locksley occipital–cervical fusion, with marked neurological improvement. Individualized case management must be based on clinical presentation, with internal fixation being the last resort.

The spinal cord is most frequently injured at the cervical level in all pediatric age groups.[3,4,10] Most spinal injuries in children younger than 8 years of age occur above the level of C-4, whereas in older children fractures/dislocations more commonly involve the lower cervical spine.[3] The atlantoaxial region in pediatric patients has several well-described characteristics that predispose it to injury: 1) increased ligamentous laxity; 2) more horizontally oriented facets; 3) less mature bone ossification; 4) higher fulcrum of cervical movement; and 5) higher inertia and torque forces associated with a larger head/body mass ratio.[2–5,9,10] The optimal management of atlantoaxial problems in children remains controversial.[7]


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