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01-03-2008 | Current Concept Review

Pediatric cervical spine instability

Authors: Ismat Ghanem, Samer El Hage, Rami Rachkidi, Khalil Kharrat, Fernand Dagher, Gabi Kreichati

Published in: Journal of Children's Orthopaedics | Issue 2/2008

Abstract

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

Pennecot GF, Gouraud D, Hardy JR, Pouliquen JC (1984) Roentgenographical study of the stability of the cervical spine in children. J Pediatr Orthop 4:346–352PubMed

Dvorak J, Panjabi MM (1987) Functional anatomy of the alar ligaments. Spine 12:183–189PubMed

Dvorak J, Schneider E, Saldinger P, Rahn B (1988) Biomechanics of the craniocervical region: the alar and transverse ligaments. J Orthop Res 6:452–461PubMed

Ebraheim NA, Yang H, Lu J, Biyani A, Yeasting RA (1997) Cartilage and synovium of the human atlanto-odontoid joint. An anatomic and histological study. Acta Anat 159:48–56PubMed

Panjabi M, Dvorak J, Crisco J, Oda T, Hilibrand A, Grob D (1991) Flexion, extension, and lateral bending of the upper cervical spine in response to alar ligament transections. J Spinal Disord 4:157–167PubMed

Clavert JM (1989) Embryologie du rachis. In: Bollini G, Bouyala JM (eds) Chirurgie et orthopédie du rachis. Sauramps médical, Montpellier, pp 21–28

O’Rahilly R, Meyer DB (1979) The timing and sequence of events in the development of the human vertebral column during the embryonic period proper. Anat Embryol 157:167–176PubMed

Sensenig EC (1957) The development of the occipital and cervical segments and their associated structures in human embryos. Contrib Embryol Carnegie Inst 36:141–151

O’Rahilly R, Muller F, Meyer DB (1980) The human vertebral column at the end of the embryonic period proper. 1. The column as a whole. J Anat 131:565–575PubMed

10.

Taylor AR, Chakravorty BC (1964) Clinical syndromes associated with basilar impression. Arch Neurol 10:475–484PubMed

11.

Nuckley DJ, Hertsted SM, Eck MP, Ching RP (2005) Effect of displacement rate on the tensile mechanics of pediatric cervical functional spinal units. J Biomech 38:2266–2275PubMed

12.

Ouyang J, Zhu Q, Zhao W, Xu Y, Chen W, Zhong S (2005) Biomechanical assessment of the pediatric cervical spine under bending and tensile loading. Spine 30:716–723

13.

Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S (2003) Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics 23:539–560PubMed

14.

Curran C, Dietrich AM, Bowman MJ, Ginn-Pease ME, King DR, Kosnik E (1995) Pediatric cervical-spine immobilization: achieving neutral position. J Trauma 39:729–732PubMed

15.

Treloar D (1994) Neutral cervical spine positioning in children. Ann Emerg Med 23:208–211PubMed

16.

Bell DF, Walker JL, O’Connor G, Tibshirani R (1994) Spinal deformity after multiple-level cervical laminectomy in children. Spine 19:406–411PubMed

17.

Ghanem I (2006) Le rachis cervical instable de l’enfant. In: Duparc J (ed) Cahiers d’enseignement de la SOFCOT. Expansion Scientifique Française, Paris, pp 289–321

18.

Buhs C, Cullen M, Klein M, Farmer D (2000) The pediatric trauma C-spine: is the ‘odontoid’ view necessary? J Pediatr Surg 35:994–997PubMed

19.

Swischuk LE, John SD, Hendrick EP (2000) Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol 30:186–189PubMed

20.

Locke GR, Gardner JI, van Epps EF (1966) Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. Am J Roentgenol 97:135–140

21.

Catell HS, Filtzer DL (1965) Pseudosubluxation and other normal variations in the cervical spine in children. J Bone Joint Surg Am 47:1295–1309

22.

Fielding JW, Cochran GVB, Lawsing JF III, Hohl M (1974) Tears of the transverse ligament of the atlas: a clinical and biomechanical study. J Bone Joint Surg Am 56:1683–1691PubMed

23.

Spierings ELH, Braakman R (1982) The management of os odontoideum. J Bone Joint Surg Br 64:422–428PubMed

24.

Volle E (2000) Functional magnetic resonance imaging—video diagnosis of soft-tissue trauma to the craniocervical joints and ligaments. Int Tinnitus J 6:134–139PubMed

25.

Weng MS, Haynes RJ (1996) Flexion and extension cervical MRI in a pediatric population. J Pediatr Orthop 16:359–363PubMed

26.

Steel HH (1968) Anatomical and mechanical considerations of the atlanto-axial articulations. J Bone Joint Surg Am 50:1481–1482

27.

Jauregui N, Lincoln T, Mubarak S, Garfin S (1993) Surgically related upper cervical spine canal anatomy in children. Spine 18:1939–1944PubMed

28.

El-Khoury GY, Clark CR, Dietz FR, Harre RG, Tozzi JE, Kathol MH (1986) Posterior atlantooccipital subluxation in Down syndrome. Radiology 159:507–509PubMed

29.

Tredwell SJ, Newman DE, Lockitch G (1990) Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 10:602–606PubMed

30.

Wiesel SW, Rothman RH (1979) Occipitoatlantal hypermobility. Spine 4:187–191PubMed

31.

Swischuk LE (1977) Anterior displacement of C2 in children: physiologic or pathologic. A helpful differentiating line. Radiology 122:759–763PubMed

32.

Ralston ME (2004) Physiologic anterior subluxation: case report of occurrence at C5 to C6 and C6 to C7 spinal levels. Ann Emerg Med 44:472–475PubMed

33.

Goni Orayen C, Perez Martinez A, Martin Martinez C, Asensio Llorente M, Peiro Ibanez JL, de Diego Suarez M (1992) Pseudosubluxation of C2-C3 in childhood: a frequent clinico-radiological diagnostic error. Esp Pediatr 36:390–392

34.

Penning L (1978) Normal movements of the cervical spine. Am J Roent 130:317–326

35.

Swischuk LE, Swischuk PN, John SD (1993) Wedging of C-3 in infants and children: usually a normal finding and not a fracture. Radiology 188:523–526PubMed

36.

Dubousset JF (1993) Approche clinique diagnostique et thérapeutique des malformations congénitales du rachis cervical chez l’enfant. In Mallet JF, Lechevallier J. Chirurgie et orthopédie du rachis cervical de l’enfant. Sauramps médical, Montpellier, pp 115–124

37.

Dubousset JF, Queneau P (1981) Les malformations de la charniere cranio-rachidienne chez l’enfant: formes anatomo-cliniques et indications therapeutiques. Rev Chir Orthop 67:383–394PubMed

38.

Bharucha EP, Dastur HM (1964) Craniovertebral anomalies (a report on 40 cases). Brain 87:469–480PubMed

39.

Wadia NH (1967) Myelopathy complicating congenital atlantoaxial dislocation (a study of 28 cases). Brain 90:449–472PubMed

40.

Greenberg AD (1968) Atlantoaxial dislocation. Brain 91:655–684PubMed

41.

Nicholson JT, Sherk HH (1968) Anomalies of the occipitocervical articulation. J Bone Joint Surg Am 50:295–304PubMed

42.

Dubousset J (1986) Torticollis in children caused by congenital anomalies of the axis. J Bone Joint Surg Am 68:178–188PubMed

43.

Hosalkar HS, Gerardi JA, Shaw BA (2001) Combined asymptomatic congenital anterior and posterior deficiency of the atlas. Pediatr Radiol 31:810–813PubMed

44.

Choit RL, Jamieson DH, Reilly CW (2005) Os odontoideum: a significant radiographic finding. Pediatr Radiol 35:803–807PubMed

45.

Fielding JW, Hensinger RN, Hawkins RJ (1980) Os odontoideum. J Bone Joint Surg Am 62:376–383PubMed

46.

Kuhns LR, Loder RT, Farley FA, Hensinger RN (1998) Nuchal cord changes in children with os odontoideum: evidence for associated trauma. J Pediatr Orthop 18:815–819PubMed

47.

Fielding JW (1964) Normal and selected abnormal motion of the cervical spine from the second cervical vertebra to the seventh cervical vertebra based on cineroentgenography. J Bone Joint Surg Am 46:1779–1781PubMed

48.

Fielding JW, Hawkins RJ (1977) Atlanto-axial rotatory fixation. J Bone Joint Surg Am 59:37–44

49.

Ghanem I, Kreichaty G, Kharrat K (1999) Atlantoaxial rotatory dislocation: pitfalls and controversies. Personal communication. Pediatric Orthopaedic Society of North America (POSNA). Lake Buena Vista, Florida

50.

Mathern GW, Batzdorf U (1989) Grisel’s syndrome: cervical spine clinical, pathologic and neurologic manifestations. Clin Orthop 244:131–146PubMed

51.

Parke WW, Rothman RH, Brown MD (1984) The pharyngovertebral veins: an anatomical rationale for Grisel’s syndrome. J Bone Joint Surg Am 66:568–574PubMed

52.

Phillips WA, Hensinger RN (1989) The management of rotatory atlanto-axial subluxation in children. J Bone Joint Surg Am 71:664–668PubMed

53.

Subach BR, McLaughlin MR, Albright AL, Pollack IF (1998) Current management of pediatric atlantoaxial rotatory subluxation. Spine 23:2174–2179PubMed

54.

Ghanem IB, London C, Delalande O, Dubousset JF (1997) Chiari I malformation associated with syringomyelia and scoliosis. Spine 22:1313–1317PubMed

55.

Caird MS, Reddy S, Ganley TJ, Drummond DS (2005) Cervical spine fracture-dislocation birth injury: prevention, recognition, and implications for the orthopaedic surgeon. J Pediatr Orthop 25:484–486PubMed

56.

McGrory BJ, Klassen RA, Chao EYS, Staeheli JW, Weaver AL (1993) Acute fractures and dislocations of the cervical spine in children and adolescents. J Bone Joint Surg Am 75:988–995PubMed

57.

Hardy J, Pouliquen JC, Liverneaux P (1990) Luxation traumatique C1-C2 chez l’enfant. Etude pronostique et indications thérapeutiques a propos de 13 cas. Rev Chir Orthop 76:17–22PubMed

58.

Filipe G, Berges O, Lebard JP, Carlioz H (1982) Instabilités post-traumatiques entre l’atlas et l’axis chez l’enfant. A propos de 5 observations. Rev Chir Orthop 68:461–469PubMed

59.

Pennecot GF, Leonard P, Peyrot Des Gachons S, Hardy JR, Pouliquen JC (1984) Traumatic ligamentous instability of the cervical spine in children. J Pediatr Orthop 4:339–345PubMed

60.

Naidisch JB, Naidisch JP, Liebeskind AL, Hyman RA (1977) The widened inter-spinal distance: a useful sign of anterior cervical dislocation in the supine frontal projection. Radiology 123:113–116

61.

Bulas DI, Fitz CR, Johnson DL (1993) Traumatic atlanto-occipital dislocation in children. Radiology 188:155–158PubMed

62.

Kenter K, Worley G, Griffin T, Fitch RD (2001) Pediatric traumatic atlanto-occipital dislocation: five cases and a review. J Pediatr Orthop 21:585–589PubMed

63.

Giguere JF, St-Vil D, Turmel A, Di Lorenzo M, Pothel C, Manseau S, Mercier C (1998) Airbags and children: a spectrum of C-spine injuries. J Pediatr Surg 33:811–816PubMed

64.

Shamoun JM, Riddick L, Powell RW (1999) Atlanto-occipital subluxation/dislocation: a “survivable” injury in children. Am Surg 65:317–320PubMed

65.

Przybylski GJ, Clyde BL, Fitz CR (1996) Craniocervical junction subarachnoid hemorrhage associated with atlanto-occipital dislocation. Spine 21:1761–1768PubMed

66.

Sponseller PD, Cass JR (1997) Atlanto-occipital fusion for dislocation in children with neurologic preservation. Spine 22:344–347PubMed

67.

Marlin AE, Williams GR, Lee JF (1983) Jefferson fractures in children. J Neurosurg 58:277–279PubMed

68.

Mikawa Y, Watanabe R, Yamano Y, Ishii K (1987) Fracture through a synchondrosis of the anterior arch of the atlas. J Bone Joint Surg Br 69:483PubMed

69.

Razif M, Lim HH (2001) Delayed decompression of chronic C1C2 subluxation in a pediatric patient with tetraplegia—is recovery possible? Med J Malaysia 56(Suppl C):76–79PubMed

70.

Wang J, Vokshoor A, Kim S, Elton S, Kosnik E, Bartkowski H (1999) Pediatric atlantoaxial instability: management with screw fixation. Pediatr Neurosurg 30:70–78PubMed

71.

Sherk HH, Nicholson JT, Chung SMK (1978) Fractures of the odontoid process in young children. J Bone Joint Surg Am 60:921–924PubMed

72.

Odent T, Langlais J, Glorion C, Kassis B, Bataille J, Pouliquen JC (1999) Fractures of the odontoid process: a report of 15 cases in children younger than 6 years. J Pediatr Orthop 19:51–54PubMed

73.

Hardy J, Pouliquen JC, Pennecot GF (1985) Les arthrodèses postérieures du rachis cervical supérieur chez l’enfant et l’adolescent a propos de 19 observations. Rev Chir Orthop 71:153–166PubMed

74.

McGrory BJ, Klassen RA, Chao EYS, Staeheli JW, Weaver AL (1993) Acute fractures and dislocations of the cervical spine in children and adolescents. J Bone Joint Surg Am 75:988–995PubMed

75.

Lawson JP, Ogden JA, Bucholz RW, Hughes SA (1987) Physeal injuries of the cervical spine. J Pediatr Orthop 7:428–435PubMed

76.

Lundy DW, Murray HH (1997) Neurological deterioration after posterior wiring of the cervical spine. J Bone Joint Surg Br 79:948–951PubMed

77.

Spitzer R, Rabinowitch JY, Wybor KC (1961) A study of the abnormalities of the skull, teeth, and lenses in mongolism. Can Med Assoc J 84:567–572PubMed

78.

Matsuda Y, Sano N, Watanabe S, Oki S, Shibata T (1995) Atlanto-occipital hypermobility in subjects with Down’s syndrome. Spine 20:2283–2286PubMed

79.

Selby KA, Newton RW, Gupta S, Hunt L (1991) Clinical predictors and radiological reliability in atlantoaxial subluxation in Down’s syndrome. Arch Dis Child 66:876–878PubMed

80.

Brockmeyer D (1999) Down syndrome and craniovertebral instability. Topic review and treatment recommendations. Pediatr Neurosurg 31:71–77PubMed

81.

White KS, Ball WS, Prenger EC, Patterson BJ, Kirks DR (1993) Evaluation of the craniocervical junction in Down syndrome: correlation of measurements obtained with radiography and MR imaging. Radiology 186:377–382PubMed

82.

Burke SW, French HG, Roberts JM, Johnston CE, Whitecloud TS, Edmunds JO Jr (1985) Chronic atlanto-axial instability in Down syndrome. J Bone Joint Surg Am 67:1356–1360PubMed

83.

Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (1995) Atlantoaxial instability in Down syndrome: subject review. Pediatrics 96:151–154

84.

Pueschel SM, Herndon JH, Gelch MM, Senft KE, Scola FH, Goldberg MJ (1984) Symptomatic atlantoaxial subluxation in persons with Down syndrome. J Pediatr Orthop 4:682–688PubMed

85.

Ghanem I, Chalouhi J, Kalouche I, Kharrat K, Dagher F (2006) Atlantoaxial instability in Down syndrome. Personal communication. Pediatric Orthopaedic Society of North America (POSNA), San Diego

86.

Karol LA, Sheffield EG, Crawford K, Moody MK, Browne RH (1996) Reproducibility in the measurement of atlanto-occipital instability in children with Down syndrome. Spine 21:2463–2467PubMed

87.

Pueschel SM, Findley TW, Furia J, Gallagher PL, Scola FH, Pezzullo JC (1987) Atlantoaxial instability in Down syndrome: roentgenographic, neurologic, and somatosensory evoked potential studies. J Pediatr 110:515–521PubMed

88.

Yong-Hing K, Kalamchi A, MacEwen GD (1979) Cervical spine abnormalities in neurofibromatosis. J Bone Joint Surg Am 61:695–699PubMed

89.

Harada T, Ebara S, Anwar MM, Okawa A, Kajiura I, Hiroshima K, Ono K (1996) The cervical spine in athetoid cerebral palsy. J Bone Joint Surg Br 78:613–619PubMed

90.

Fuji T, Yonenobu K, Fujiwara K, Yamashita K, Ebara S, Ono K, Okada K (1987) Cervical radiculopathy or myelopathy secondary to athetoid cerebral palsy. J Bone Joint Surg Am 69:815–821PubMed

91.

Nishihara N, Tanabe G, Nakahara S, Imai T, Murakawa H (1984) Surgical treatment of cervical spondylotic myelopathy complicating athetoid cerebral palsy. J Bone Joint Surg Br 66:504–508PubMed

92.

Reese ME, Msall ME, Owen S, Pictor SP, Paroski MW (1991) Acquired cervical impairment in young adults with cerebral palsy. Dev Med Child Neurol 33:153–158PubMed

93.

Aronson DD, Kahn RH, Canady A, Bollinger RO, Towbin R (1991) Instability of the cervical spine after decompression in patients who have Arnold-Chiari malformation. J Bone Joint Surg Am 73:898–906PubMed

94.

Cattell HS, Clark GL Jr (1967) Cervical kyphosis and instability following multiple laminectomies in children. J Bone Joint Surg Am 49:713–720PubMed

95.

Francis WR Jr, Noble DP (1988) Treatment of cervical kyphosis in children. Spine 13:883–887PubMed

96.

Ghanem I, Zeller R, Dubousset J (1996) Tumeurs extra-osseuses du rachis chez l’enfant et l’adolescent. Complications rachidiennes. Rev Chir Orthop 82:313–320PubMed

97.

McLaughlin MR, Wahlig JB, Pollack IF (1997) Incidence of postlaminectomy kyphosis after Chiari decompression. Spine 22:613–617PubMed

98.

Sim FH, Svien HJ, Bickel WH, Janes JN (1974) Swan-neck deformity following extensive cervical laminectomy. J Bone Joint Surg Am 56:564–580PubMed

99.

Yasuoka S, Peterson H, Laws ER Jr, MacCarty CS (1981) Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults. Neurosurgery 9:145–152PubMed

100.

Meyer NJ, Flatley TJ, Dunn DD (2003) Superiorly based laminoplasty in children: average 6.8-year follow-up of 21 patients. J Spinal Disord Tech 16:156–162PubMed

101.

Raimondi AJ, Guiterrez FA, DiRocco C (1976) Laminectomy and total reconstruction of posterior spinal arch for spinal canal surgery in childhood. J Neurosurgery 45:555–560

102.

Hensinger RN, DeVito PD, Ragsdale CG (1986) Changes in the cervical spine in juvenile rheumatoid arthritis. J Bone Joint Surg Am 68:189–198PubMed

103.

Fried JA, Athreya B, Gregg JR, Das M, Doughty R (1983) The cervical spine in juvenile rheumatoid arthritis. Clin Orthop 179:102–106PubMed

104.

Dickerman RD, Colle KO, Bruno CA Jr, Schneider SJ (2004) Craniovertebral instability with spinal cord compression in a 17-month-old boy with Sly syndrome (mucopolysaccharidosis type VII): a surgical dilemma. Spine 29:92–94

105.

Dullenkopf A, Holzmann D, Feurer R, Gerber A, Weiss M (2002) Tracheal intubation in children with Morquio syndrome using the angulated video-intubation laryngoscope. Can J Anaesth 49:198–202PubMed

106.

Morell RC, Colonna DM, Mathes DD, Wilson JA (1997) Fluoroscopy-assisted intubation of a child with an unstable subluxation of C1/C2. J Neurosurg Anesthesiol 9:25–28PubMed

107.

Pouliquen JC, Pennecot GF, Guyonvongh G (1980) Charnière crânio-rachidienne et maladie de Morquio. Rev Chir Orthop 66(suppl 1):107–108

108.

Glorion C, Langlais J, Finidori G (2004) Monographie du GEOP. Sauramps

109.

Banks JT, Wellons JC III, Tubbs RS, Blount JP, Oakes WJ, Grabb PA (2003) Cervical spine involvement in Larsen’s syndrome: a case illustration. Pediatrics 111:199–201PubMed

110.

Bellon JM, Filipe G (1987) Problemes rachidiens rencontres au cours du syndrome de Larsen. A propos de 3 cas. Rev Chir Orthop 73:57–62PubMed

111.

Lefort G, Mourad H, Deniscault G, Daoud S (1983) Dislocation du rachis cervical supérieur dans le syndrome de Larsen. Chir Ped 24:211–212

112.

Tobias JD (1996) Anesthetic implications of Larsen syndrome. J Clin Anesth 8:255–257PubMed

Title: Pediatric cervical spine instability
Authors: Ismat Ghanem
Samer El Hage
Rami Rachkidi
Khalil Kharrat
Fernand Dagher
Gabi Kreichati
Publication date: 01-03-2008
Publisher: Springer Berlin Heidelberg
Published in: Journal of Children's Orthopaedics / Issue 2/2008
Print ISSN: 1863-2521
Electronic ISSN: 1863-2548
DOI: https://doi.org/10.1007/s11832-008-0092-2

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Pediatric cervical spine instability

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