Outcomes of Spinal Fusion for Cervical Kyphosis in Children with Neurofibromatosis.
BACKGROUND
Cervical kyphosis may occur with neurofibromatosis type I (NF1) and is often associated with vertebral dysplasia. Outcomes of cervical spinal fusion in patients with NF1 are not well described because of the rarity of the condition. We aimed to (1) characterize the clinical presentation of cervical kyphosis and (2) report the outcomes of posterior and anteroposterior cervical fusion for the condition in these children.


METHODS
The medical records and imaging studies of 22 children with NF1 who had undergone spinal fusion for cervical kyphosis (mean, 67°) at a mean age of 11 years and who had been followed for a minimum of 2 years were reviewed.


RESULTS
Thirteen children presented with neck pain; 10, with head tilt; 9, with a previous cervical laminectomy or fusion; and 5, with a neurologic deficit. Two patients had spontaneous dislocation of the mid-cervical spine without a neurologic deficit. Eleven had scoliosis, with the major curve measuring a mean of 61°. Nine patients underwent posterior and 13 underwent anteroposterior surgery. Twenty-one received spinal instrumentation, and 1 was not treated with instrumentation. Preoperative halo traction was used for 9 patients, and it reduced the mean preoperative kyphosis by 34% (p = 0.0059). At the time of final follow-up, all spinal fusion sites had healed and the cervical kyphosis averaged 21° (mean correction, 69%; p < 0.001). The cervical kyphosis correction was significantly better after the anteroposterior procedures (83%) than after the posterior-only procedures (58%) (p = 0.031). Vertebral dysplasia and erosion continued in all 17 patients who had presented with dysplasia preoperatively. Thirteen patients had complications, including 5 new neurologic deficits and 8 cases of junctional kyphosis. Nine patients required revision surgery. Junctional kyphosis was more common in children in whom ≤5 levels had been fused (p = 0.054).


CONCLUSIONS
Anteroposterior surgery provided better correction of cervical kyphosis than posterior spinal fusion in children with NF1. Erosion of vertebral bodies continued during the postoperative follow-up period in all patients who had presented with dysplastic changes preoperatively. The cervical spine should be screened in all children with NF1. Fusion should include at least 6 levels to prevent junctional kyphosis.


METHODS
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Department of Pediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland ilkka.helenius@utu.fi.
Ilkka J
IJ
Helenius
Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.
Paul D
PD
Sponseller
Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.
William
W
Mackenzie
Service d'Orthopédie Pédiatrique, Hôpital d'Enfants Clocheville, CHRU de Tours, Université François-Rabelais de Tours, PRES Centre Val de Loire Université, France.
Thierry
T
Odent
Texas Children's Hospital, Houston, Texas.
John P
JP
Dormans
Miami Children's Hospital, Miami, Florida.
Jahangir
J
Asghar
Texas Scottish Rite Hospital, Dallas, Texas.
Karl
K
Rathjen
Shriners Hospitals for Children, Philadelphia, Pennsylvania.
Joshua M
JM
Pahys
BC Children's Hospital, Vancouver, British Columbia, Canada.
Firoz
F
Miyanji
Children's Hospital of Boston, Boston, Massachusetts.
Daniel
D
Hedequist
Arnold Palmer Hospital for Children, Orlando, Florida.
Jonathan H
JH
Phillips
D000293:Adolescent; D002574:Cervical Vertebrae / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007738:Kyphosis / Q000150:complications / Q000601:surgery*; D008297:Male; D017253:Neurofibromatoses / Q000150:complications*; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000379:methods*; D016896:Treatment Outcome