Pediatric atlas anatomy and its implications for fracture treatment: an anatomical and radiological study.

INTRODUCTION AND OBJECTIVES: The objective of the study was: (1) to describe changes in the shape of the atlas during growth, including gender and side differences; (2) to assess the dimension essential for identification of the optimal entry point; (3) to determine the age limit for a safe insertion of 3.5-mm screws into the lateral masses according to our own limiting parameters. MATERIALS AND METHODS: Dimensions of the atlas were measured on 200 CT scans of the craniocervical junction in individuals aged 0-18 years and on 34 anatomical specimens of the first cervical vertebra (aged 2.5-18 years). Both series were divided according to the gender and age. The values measured on CT scans were used for statistical comparison of data in boys and girls and comparison of the right and left sides. RESULTS: The atlas reaches its maximum growth rate between 0 and 2 years of age, then the growth decelerates and continues until the age of 18 years. The proportion of dimensions of C1 vertebral foramens changes with age. The youngest children show a relatively greater distance from the left to the right medial pedicle; around the age of 5 the values get even and subsequently the distance from the inner wall of anterior to posterior arch gets relatively greater. The transverse foramen has a slightly oval shape throughout the period of growth. Statistically significant differences between boys and girls were observed primarily between 12 and 18 years of age. CONCLUSION: The study has proved adequate size of lateral masses for insertion of 3.5-mm screws in all patients from the age of 5 years. In younger children, the patient´s anatomy should be respected and the surgical technique tailored accordingly.

High-grade high-dysplastic lumbosacral spondylolisthesis in children treated with complete reduction and single-level circumferential fusion: A prospective case series.

Introduction: Surgical treatment of high-grade developmental spondylolisthesis remains controversial with paucity of data reporting complete reduction of the deformity, especially in pediatric patients. Research question: To assess efficacy and safety of complete reduction and circumferential L5-S1 fusion in children with high-grade high-dysplastic spondylolisthesis. Emphasis was placed on fusion rates, correction of lumbosacral deformity and long-term clinical outcomes by means of patient-reported outcome measures (PROMs). Material and methods: Consecutive series of 18 pediatric patients referred to surgery over an 11-years period. Several radiographic variables and PROMs were collected pre- and post-surgery with minimum follow-up of 2-years. Results: The mean age of cohort was 12.9 years with a mean follow-up of 7.8 years. Postoperatively, the mean slip was reduced from 64.4±9.8% to 4.5±5.9% with no loss of correction during follow-up. PROMs significantly improved following the index procedure (p<0.0001). Lumbo-pelvic parameters improved after surgery, including SS, but not PT. Development of adjacent level spondylolisthesis was noted in eight subjects (44%), two of these patients required additional surgery. Posterolateral and anterior fusion was obtained in 100% and 78% of cases, respectively. One patient developed a transient right-sided L5 nerve paresis after surgery that gradually resolved within one year post-surgery. Preoperatively, we recorded three patients with L5 nerve root motor deficit, which resolved completely in two cases and in one patient remained unchanged. Discussion and conclusion: Complete reduction can safely be accomplished without an increased risk of nerve root injury. Coupled with single-level circumferential fusion, it provides high fusion rates with satisfactory spino-pelvic alignment.

Pediatric dens anatomy and its implications for fracture treatment: an anatomical and radiological study.

PURPOSE: Separation of C2 growth plates and dens fractures are the most common types of injuries to the axis (C2) in children. Operative treatment of these injuries with the use of direct osteosynthesis requires a profound knowledge of detailed anatomy and dimensions of the axis. The main issue addressed by the study was the age at which the size of the dens is adequate at all levels to accommodate two screws, and the size of the posterior dens angulation angle (PDAA) in a healthy child in individual age periods. METHODS: Dimensions and angles of the dens and C2 in individual age categories in both boys and girls were measured in a series of 203 CT scans of individuals 0-18 years old and on anatomical specimens (42 samples). In addition, 5 histological series of this region from the fetal period were reviewed. RESULTS: Dimensions of the dens gradually increase with age, with a considerable acceleration during growth spurt periods that are different in boys and girls. PDAA is markedly changing with age; in the fetal period, the dens shows a slight anterior angulation which gradually transforms into posterior angulation, as early as between 4 and 6 years of age. The screw insertion angle changes accordingly. CONCLUSION: During growth, there occur changes in PDAA that should be respected in evaluation of transformation of anterior into posterior angulation, as shown by imaging methods. Dens dimensions theoretically allow insertion of two 3.5 mm screws as early as from the age of 1 year.