title: Avoiding early complications and reoperation during occipitocervical fusion in pediatric patients.
abstract: OBJECTIVE
  Surgical arthrodesis for pediatric occipitocervical (OC) instability has a high rate of success in a wide variety of challenging circumstances; however, identifying potential risk factors can help to target variables that should be the focus of improvement. The aim of this paper was to examine risk factors predictive of failure in a population of patients who underwent instrumented OC arthrodesis using a uniform surgical philosophy.
  
  
  METHODS
  The authors conducted a retrospective cohort study of pediatric patients who underwent OC fusion from 2001 to 2013 at a single institution to determine risk factors for surgical failure, defined as reoperation for revision of the arthrodesis or instrumentation. The primary study outcome was either radiographic confirmation of successful OC fusion or surgical failure requiring revision of the arthrodesis or instrumentation. The secondary outcome was the underlying cause of failure (hardware failure, graft failure, or infection). Univariate analysis was performed to assess the association between outcome and patient demographics, cause of OC instability, type of OC instrumentation, bone graft material, biological adjuncts, and complications.
  
  
  RESULTS
  Of the 127 procedures included, 20 (15.7%) involved some form of surgical failure and required revision surgery. Univariate analysis revealed that patients with deep wound infections requiring debridement were more likely to require surgical revision of the hardware or graft (p = 0.002). Subgroup analysis revealed that patients with skeletal dysplasia or congenital spinal anomalies were more likely to develop hardware failure than patients with other causes of OC instability (p = 0.020). Surgical failure was not associated with the method of C-2 fixation, type of rigid OC instrumentation, bone graft material, use of bone morphogenetic protein or biological adjuncts, cause of instability, sex, age, or having previous OC fusion operations.
  
  
  CONCLUSIONS
  Pediatric patients in the present cohort with postoperative wound infections requiring surgical debridement had higher surgical failure rates after OC fusion. Those with skeletal dysplasia and congenital spinal anomalies were more likely to require reoperation for hardware failure. Better understanding of the mode of surgical failure may enable surgeons to develop strategies to decrease the need for reoperation in pediatric patients with OC instability.
authors.affiliation: Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children's Hospital, University ofUtah, Salt Lake City, Utah; and.
authors.forename: Marcus D
authors.initials: MD
authors.lastname: Mazur
authors.forename: Walavan
authors.initials: W
authors.lastname: Sivakumar
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
authors.forename: Jaes
authors.initials: J
authors.lastname: Jones
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Brockmeyer
mesh_terms: D000293:Adolescent; D000367:Age Factors; D065634:Cerebrospinal Fluid Leak / Q000209:etiology / Q000601:surgery; D002574:Cervical Vertebrae; D002648:Child; D002675:Child, Preschool; D003646:Debridement; D005260:Female; D006801:Humans; D007223:Infant; D007593:Joint Instability / Q000601:surgery*; D008297:Male; D009777:Occipital Bone; D011237:Predictive Value of Tests; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D013123:Spinal Fusion / Q000009:adverse effects*; D013530:Surgical Wound Infection / Q000209:etiology / Q000601:surgery*
keywords: BMP = bone morphogenetic protein; DBM = demineralized bone matrix; OC = occipitocervical; complications; craniovertebral junction; instability; instrumentation; occipitocervical fusion; pediatric; spine