title: Occipitocervical fusion using a contoured rod and wire construct in children: a reappraisal of a vintage technique.
abstract: OBJECTIVE
  Many methods to stabilize and fuse the craniocervical junction have been described. One of the early designs was a contoured (Luque) rod fixated with wires, the so-called Hartshill-Ransford loop. In this study, the authors report their 20-year experience with this surgical technique in children.
  
  
  METHODS
  The authors reviewed the medical records of patients 18 years of age or younger who underwent dorsal occipitocervical fusion procedures between March 1992 and March 2012 at Le Bonheur Children's Hospital using a contoured rod and wire construct. Data on basic patient characteristics, causes of instability, neurological function at presentation and at last follow-up, details of surgery, complications, and radiographic outcome were collected.
  
  
  RESULTS
  Twenty patients (11 male) were identified, with a mean age of 5.5 years (range 1-18 years) and a median follow-up of 43.5 months. Fourteen patients had atlantooccipital dislocation, 2 patients had atlantoaxial fracture-dissociations, 2 had Down syndrome with occipitocervical and atlantoaxial instability, 1 had an epithelioid sarcoma from the clivus to C-2, and 1 had an anomalous atlas with resultant occipitocervical instability. Surgical stabilization extended from the occiput to C-1 in 3 patients, C-2 in 6, C-3 in 8, and to C-4 in 3. Bone morphogenetic protein was used in 2 patients. Two patients were placed in a halo orthosis; the rest were kept in a hard collar for 6-8 weeks. All patients were neurologically stable after surgery. One patient with a dural tear experienced wound dehiscence with CSF leakage and required reoperation. Eighteen patients went on to achieve fusion within 6 months of surgery; 1 patient was initially lost to follow-up, but recent imaging demonstrated a solid fusion. There were no early hardware or bone failures requiring hardware removal, but radiographs obtained 8 years after surgery showed that 1 patient had an asymptomatic fractured rod. There were no instances of symptomatic junctional degeneration, and no patient was found to have increasing lordosis over the fused segments. Five (31%) of the 16 trauma patients required a shunt for hydrocephalus.
  
  
  CONCLUSIONS
  Despite the proliferation of screw-fixation techniques for craniocervical instability in children, the contoured rod-wire construct remains an effective, less expensive, and technically easier alternative that has been in use for almost 30 years. It confers immediate stability, and therefore most patients will not need to be placed in a halo device postoperatively. A secondary observation in our series was the high (30%) rate of hydrocephalus requiring a shunt in patients with traumatic instability.
authors.affiliation: Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee 38120, USA. pklimo@semmesmurphey.com
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
authors.forename: Nelson
authors.initials: N
authors.lastname: Astur
authors.forename: Kyle
authors.initials: K
authors.lastname: Gabrick
authors.forename: William C
authors.initials: WC
authors.lastname: Warner
authors.forename: Michael S
authors.initials: MS
authors.lastname: Muhlbauer
mesh_terms: D000293:Adolescent; D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001269:Atlanto-Occipital Joint / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001696:Biomechanical Phenomena; D019485:Bone Morphogenetic Proteins / Q000627:therapeutic use; D001858:Bone Nails; D001864:Bone Wires; D001915:Braces; D002557:Cerebrospinal Fluid Shunts; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D006849:Hydrocephalus / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D015994:Incidence; D007223:Infant; D004204:Joint Dislocations / Q000601:surgery; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008499:Medical Records; D011859:Radiography; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D013714:Tennessee / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D019485:Bone Morphogenetic Proteins