When It Comes to Cervical Spine Surgery, Kids Get Special Treatment

May. 11, 2018

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We all want our children to grow and develop well. Although most kids will do just fine with proper routine care, occasionally a medical problem crops up that can keep kids from growing and developing as they should. When the problem involves the spine and the solution is surgical, preserving the child’s ability to grow normally is a big concern.

Neurosurgeons Dr. Richard C.E. Anderson and Dr. Peter D. Angevine of the Department of Neurological Surgery at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital recently teamed up with their colleagues in Columbia’s Department of Orthopedics to author an article on a promising new surgical technique that allows for greater preservation of spinal growth in children. The procedure, known as temporary occipital fixation, was used on a series of young patients who had problems affecting the upper (cervical) spine.

In some children the spinal bones, or vertebrae, are not lined up correctly. It’s not always clear why this happens, but some children are born with this kind of malformation of the spine. The article mentions a few examples.

One problem, known as kyphosis, occurs when the spine has an abnormal forward curve. Another problem, dislocation, is when one vertebra is located too far in front of or behind the other vertebrae. Deformities in the spine such as these can keep the spine from developing properly. Also, since the spine contains the spinal cord—a long column carrying nerves from the brain to the body—deformities can put pressure on nerves, leading to problems with movement or sensation.  

In order to correct these problems—in other words, to get the vertebrae lined up correctly—the surgeon will normally perform a type of surgery known as spinal instrumentation and fusion. As the name implies, two processes are involved. First, rods and screws are attached to the vertebrae to align them correctly. Then, pieces of bone—either from another part of the patient’s body or from a donor—are placed in between the vertebrae. This is known as a bone graft.

The bone graft, along with the rods that are inserted, forms a bridge between the patient’s own vertebrae to securely keep them in place. Over time, the grafted bone fuses (combines) with the vertebrae, much like two parts of a healing broken bone will fuse. This makes the corrected spine more stable.

Surgeons perform spinal fusion in all age groups for a variety of conditions. But children’s spines often need to be treated differently. One issue is that the smaller bones and immature bone tissue make it more difficult for surgeons to place rods and screws.

One way to solve this problem is to use the base of the skull, or occiput, to “anchor” the hardware and place a bone graft between the occiput and the top cervical vertebra. This holds the spine in one place all the way from the skull down through the cervical area. However, this creates two issues. First, fixing the upper spine to the skull may inhibit the spine’s ability to grow with the child. Second, it lessens the ability to move the head on the neck, something which may interfere with the child’s motor development.

How can surgeons get around these problems? How can they keep the spine stable, yet allow for movement and growth?

Drs. Anderson and Angevine and their co-authors describe a solution they have named temporary occipital fixation. In this procedure, the surgeon will place screws in the vertebrae, plus screws at the base of the skull. Once this is done, he will move the vertebrae into the right place and correct the deformity.

Next, the surgeon will attach a pair of temporary rods running from the hardware at the base of the skull down the spine. He’ll then place bone grafts between the cervical vertebrae. But in this case, there is no need to place a bone graft between the skull and the upper cervical vertebra; the temporary rods act to keep the grafts and the vertebrae in the right place.

A year later, the bone grafts have had a chance to fuse with the child’s vertebrae and the spine is more stable. Because of this, the rods attaching the spine to the base of the skull are no longer needed. The surgeon will then remove the rods and screws at the base of the skull. Because there is no bone graft involving the skull and the uppermost bones of the spine, the spine will have room to grow, and the head can move more freely.

Drs. Anderson and Angevine and their colleagues* reported on this procedure in a recent article in Neurosurgical Focus. And since the authors will continue to follow these patients as they grow, they’ll learn even more about how this surgical advance affects the children’s progress.
To view before and after photos from case reports in the article from Neurosurgical Focus, such as the one below, please view the full article here.

Image from Neurosurgical Focus, DOI: 10.3171/2017.7.FOCUS17287
Image from Neurosurgical Focus, DOI: 10.3171/2017.7.FOCUS17287

Learn more about Dr. Anderson on his bio page here.

Learn more about Dr. Angevine on his bio page here.

*Full list of authors: Brian J. Kelley, M.D., Ph.D., Anas A. Minkara, B.H.S., Peter D. Angevine, M.D., M.P.H., Michael G. Vitale, M.D., M.P.H., Lawrence G. Lenke, M.D., and Richard C.E. Anderson, M.D.

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