Complications of Therapies for Cervical Spine Trauma in Children

Surgical

General

  • Wound complications: Wound hematoma or deep infection are unusual complications of cervical spine surgery in children. Anterior hematomas in particular should be evacuated promptly because of the risk of airway compression. Deep infections usually require re-exploration to obtain pus for microbiological confirmation, drainage of purulent collections, and tissue debridement. Deep infections can usually be treated without recourse to removal of instrumentation.
  • Construct failure: Displacement of metalwork or grafts detected in the early postoperative period should be dealt with by reoperation and repositioning. Long-term success depends on optimal positioning of hardware.
  • Construct malplacement: Malposition of screws in the cervical spine can result in direct spinal cord injury, CSF leak, nerve root injury, and vertebral artery injury. Thorough knowledge of the bony anatomy, landmarks, and trajectories for screw placement are essential. Intraoperative X-ray screening, spinal cord monitoring, and new techniques of image guidance may each help reduce the risk of screw malplacement, but none of these are a substitute for careful preoperative planning and sound knowledge of the surgical anatomy.

Postfusion deformity

Traditional concerns that fixation and fusion in the pediatric spine would lead to stunted growth and deformity were perhaps overstated. Recent evidence from longer-term studies suggest favorable late outcomes.

  • No evidence for abnormality 4–5 years after anterior fusion: Patients who have undergone anterior cervical fusion with 4- to 5-year follow-up show no abnormal cervical growth or alignment (20,45).
  • No evidence for abnormality after posterior fusion: Posterior fixation across the craniocervical junction often does not have a significant effect on growth and alignment by one report (3)

Creeping fusion

  • Fusion beyond intended levels: Fusion may continue beyond intended levels and should be borne in mind when planning fusion construct and carrying it out. The dissection and bone disruption outside the intended fusion site should be kept at a minimum.
    Duration of survival
  • Increased risk for adjacent degeneration:  In contrast with adult patients, many pediatric patients have 60–80 years of additional life expectancy. For this reason, adjacent-level disease and accelerated degeneration are more important concepts in this age group. Minimizing tissue damage may decrease the risks of these complications.