Challenges in Fixation of Craniovertebral Junction in Children

Congenital anomalies or trauma to craniovertebral junction (CVJ) is common in children and needs fixation of bones at CVJ. Thin and delicate bones make this task challenging. Many options available are occiput–C2 or C1-C2 fixation with sublaminar wire. In pediatric patients nonabsorbable, braided suture can be used instead to prevent cut through. There is an option of curved Steinman pin which is fixed with wires to the lamina. In occipitalized atlas, creating an artificial atlas is an option. Newer methods include use of screws and rods or plate. This can fix occiput to C1 or C2 or C1lateral mass with C2 transpedicular screws. Lateral mass of C1 at any age group is capable of holding screws but C2 pedicle may be below 4 mm and it may be difficult to negotiate a 3.5-mm screws. This is the minimum diameter of screw available in International market. Translaminar screws can be placed in such cases if the lamina is of adequate thickness. Else, screws can be placed directly into the body of C2. Opening of C1C2 joints is important for a good fusion rate; hence, rigid fixation has a major role to play. We present an experience of 14 patients where different methods were used and there results are discussed in detail. CT scan, X-rays, and MRI were done in all cases. We found that rigid fixation is a better method if possible in children. However, size of pedicle or lateral mass is a major hindrance. The choice of fixation method is individualized based on child’s age, pathology and bone health. Rigid immobilization with collar is required in all cases for 6 weeks.