Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/16/2022 CASE REPORT SPINE Volume 37, Number 6, pp E400–E407 ©2012, Lippincott Williams & Wilkins E400 www.spinejournal.com March 2012 Internal Stabilization of a Flexion-Distraction Injury of the Upper Cervical Spine of a Toddler A New Technique and Literature Review Kamal Hamoud, MD, MCh(Orth), Israel Hershkovitz, PhD, Amos Hanani, MD, Leur Marom, MD , and Janan Abbas, MSc Study Design. A case report and literature review. Objective. To present a new and simple technique of fixation without fusion of a rare unstable Salter-Harris type I injury in the upper cervical spine of a 23-month-old toddler. Summary of Background Data. Surgical treatment of unstable pediatric cervical spine injuries most commonly involves posterior fusion with internal fixation, usually posterior wiring. Methods. Detailed description of the surgical procedure carried out for fixating an unstable flexion-distraction injury in a 23-month- old toddler, with severe head injury and pneumothorax, is presented. Results. A rare unstable flexion-distraction injury in the upper cervical spine of a toddler was successfully treated with a posterior Number 2 Vicryl (polyglactin 910; ETHICON Division of Johnson & Johnson) suture fixation, with good healing of the ligaments and end plates, without fusion. Preservation of motion was achieved without obvious instability at 28 months postsurgery. Conclusion. In selected cases of cervical spine injuries in the young pediatric population, simple stabilization of the spine using degradable Number 2 Vicryl (polyglactin 910) sutures with minimal exposure can provide sufficient stability until healing occurs. Advantages are that fusion is avoided and motion preserved. Key words: cervical spine, internal fixation, pediatric spine, Vicryl (polyglactin 910) suture. Spine 2012;37:E400–E407 I n the pediatric population, approximately 40% to 60% of all spinal injuries occur in the cervical region. 1 –3 Literature points to a division of patients into a group aged 8 years or younger with predominantly upper cervical spine injuries and an older group of patients with commonly lower cervical spine injuries, or injuries of both levels. 4 –7 Cervical injuries in infants and toddlers usually result from falls, motor vehicle accidents, and nonaccidental trauma. 8 –10 Surgical treatment may be required in cases of persistent malalignment or severe instability. 11 Reported surgical treatment of pediatric cervical spine injuries and instability has commonly involved fusion with instrumentation, usually posterior wiring. 12 –22 To date, no surgical technique that includes limited exposure and fixa- tion without fusion in the pediatric cervical spine has been described. In this study, we present a new method for stabili- zation of a rare unstable injury of the upper cervical spine in a toddler, using the posterior approach with a limited exposure of the spinous processes and using absorbable sutures, with- out fusion. CASE REPORT The patient, a 23-month-old toddler, was involved in a road traffic accident as a pedestrian. He was thrown a long distance from the site of the accident. A tracheal intubation was per- formed on the spot by the rescue team, and the patient was transferred to our hospital by helicopter. No information was available concerning his initial consciousness or neurological status. Investigation in the emergency department, including computed tomography and magnetic resonance imaging of the head and the neck, revealed a head trauma with diffuse axonal injury and subarachnoid hematoma, severe flexion-distraction injury with anterior dislocation of C2–C3 (Figures 1–4). In addition, 3 fractured ribs on the right side with pneumotho- rax were diagnosed and treated with a chest tube. The patient was operated on immediately under general anesthetics, using the posterior approach to the upper cervi- cal spine. A Number 2 coated Vicryl suture (polyglactin 910; ETHICON Division of Johnson & Johnson) was used for sta- bilizing C2–C3. This is an absorbable suture composed of a copolymer made from 90% glycolide and 10% l-lactide and coated with a mixture of equal parts of copolymer of glycolide and lactide (polyglactin 370) and calcium stearate. 23 From the Spine Unit, Rambam Health Care Campus, Haifa, Israel (Drs Hamoud, Hanani, and Marom); Poriya Medical Center, Tiberias, Israel (Dr Hamoud); Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr Hershkovitz and Mr Abbas); and Department of Physical Therapy, Zefat Academic College, Zefat, Israel (Dr Hamoud and Mr Abbas). Acknowledgment date: March 1, 2011. First revision date: June 7, 2011. Acceptance date: July 18, 2011. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Kamal Hamoud, MD, MCh(Orth), Spine Unit, Rambam Healthcare Campus, 6 Ha’Aliya Street, POB 9602, Haifa 31096, Israel. E-mail: k_hamoud@yahoo.com DOI: 10.1097/BRS.0b013e31822e82e5 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.