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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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3. Associated anomalies.
a. Genitourinary (35%).
b. Central nervous system.
c. Cardiopulm onary.
d. Sprengel’s deformities (40%).
e. Upper extrem ity anomalies.
f. Scolio sis (6 0 %).
4. Clinical ndings.
a. Low posterior neck line.
b. Short neck.
c. Limited neck motion.
22 Pediat ric Cervical Spine Disorders 257
(1) The majority of patients have a norm al appearance with m ild
restriction of motion.
5. Radiographic ndings.
a. Vertebral synostoses.
b. Flattening and widening of the vertebral bodies.
c. Absent disk spaces or hypoplasia.
6. Treatment.
a. The majority of patients are asymptomatic.
(1) Sym ptoms may appear later in life.
b. Conservative treatment is indicated for most patients.
(1) Anti-in am m atory medications.
(2) Exercise program .
c. Fusion may be indicated in select patients with instability and spinal cord
impingem ent.
C. An om a lie s of t h e o d on to i d .
1. Etiology.
a. Trauma.
(1) Salter I fracture with a nonunion (Fig. 22.5).
b. Congenital.
(1) Failure to fuse (normally fuses at 3–6 years).
2. Clinical ndings.
a. Neck pain.
b. Torticollis.
c. Neurological symptom s.
3. Treatment.
a. Conservative if stable.
b. Surgical intervention.
(1) Indications for surgical stabilization.
(a) More than 7 to 10 mm of instability even without symptom s.
(b) Atlantoden s interval (ADI) > 4.5 m m w ith exion -extension lm s
and SAC < 13 m m.
(2) Technique.
(a) C1–C2 fusion with wire xation:
i. Th e ver tebral artery is proport ion ally closer to the m idlin e in
the child.
258
22 Pediat ric Cervical Spine Disorders
Fi g . 2 2 . 5 Illu st ra t io n o f t h e t h re e t yp e s o f o d o n to id fr a ct u re s.
(b) Preoperative tract ion an d reduct ion m ay be necessary.
(c) Postoperative halo vest stabilization.
(d) C1–C2 fusion with C1–C2 transarticular screw xation:
i. More rigid and avoids halo vest postoperatively.
(e) Occiput–C2 fusion is necessary if the C1 ring is de cient.
D. Congenital at lan to - occipit al fu sion.
1. Failure of segmentation.
2. Most commonly recognized anomaly of the craniovertebral junction.
3. Prone to C1–C2 instability if associated with C2–C3 fusion or anomalies of
the odontoid (70%).
4. Associated with dwar sm, funnel chest, pes cavus, syndactyly, cleft palate,
and genitourinary anomalies.
5. Clinical ndings.
a. Short neck, restricted neck motion, and torticollis.
b. Fifty percent have relative basilar impressions secondary to diminished
vertebral heigh t of the atlas ring.
c. Neurological involvem ent, especially if the odontoid is above the foram en
magnum level.
6. Radiographic ndings.
a. Flexion-extension view.
(1) ADI > 3 to 4 mm.
(2) SAC < 13 mm .
7. Treatment.
a. Conservative treatment.
(1) Cervical collar.
(2) Traction.
b. Surgery.
(1) Occiput–C1–C2 fusion after traction and reduction if C1–C2
instability is present.
(2) Posterior decom pression and fusion if there is posterior com pression
of the spinal cord.
22 Pediat ric Cervical Spine Disorders 259
E. To r t ico llis ( w r y n eck ).
1. Typically discovered in the rst 6 to 8 weeks of life.
2. Ischemia and contracture of the sternocleidomastoid muscle may be
pathogenic.
a. Venous occlusion and brous replacement of tissue secondary to
int rauterine position.
3. Clinical ndings:
a. Twenty percent associated incidence of congenital hip dislocation.
b. Eighty- ve percent of cases involve the right side.
c. The head is tilted toward the involved side, and the chin is rotated to the
opposite side.
d. Soft, nontender enlargement beneath the skin resolves in 6 to 12 weeks.
e. Contracture of the m uscle follows with decreased range of motion of the
neck.
f. Facial asym m et r y an d m ild d or sal co m p en sator y scoliosis.
4. Di erential diagnosis:
a. Congenital cervical spine anomalies.
b. Extraocular muscle imbalance.
5. Treatment:
a. Stretching exercise, positioning, and brace.
(1) Eight y- ve to 90% response within 1 year.
b. Surgical indications.
(1) After 1 year if persistent facial asym m etry.
(2) Head tilting.
(3) Decreased range of m otion.
c. Surgical options.
(1) Unipolar/bipolar release.
(a) Bipolar release with Z-lengthening gives the best results.
i. Be careful of the posterior auricular ner ve an d spinal
accessory nerve.
F. At l a n t o a x i a l i n s t a b i l i t i e s .
1. Etiologies.
a. In ammation.
(1) Pharyngeal infection (Grisel’s syndrom e).
(2) Juvenile rheum atoid arthritis.
b. Down’s syndrome.
(1) Twent y- ve percent incidence.
(2) Boys older than 10 years are at greater risk for myelopathy following
rupture of transverse ligament.
c. Dysplasia.
(1) Achondroplasia.
(2) Diastrophic dysplasia.
(3) Spondyloepiphyseal dysplasia.
(4) Morquio’s syndrome.
(5) Larsen’s syndrom e.
d. Congenital anomalies.
260
22 Pediat ric Cervical Spine Disorders
e. Spontaneous rotatory subluxation of C1–C2.
(1) Fielding classi cation.
(a) Type I.
i. Sim ple shift w ith ou t displacem ent .
(b) Type II.
i. Less than 5 m m of C1–C2 displacem en t .
(c) Type III.
i. Greater th an 5 m m of C1–C2 displacem ent.
2. Treatment.
a. Conservative.
(1) Mild rotatory deform ity.
(a) Collar.
(b) Analgesics.
b. Surgical.
(1) C1–C2 fusion if neurological sym ptom s present.
(2) SAC < 13 mm .
G. Tr a u m at ic ce r vical in ju r ie s.
1. Cervical spine fractures.
a. Vertebral fractures account for 2 to 3% of all childhood injuries.
b. Fifteen percent of all spinal cord injuries occur in children.
c. Under 10 years, bony injuries are less com m on.
d. Patient positioning may be a problem in children under 5 years.
(1) The head is larger than the trunk.
(a) The back board may displace the fracture.
(b) Keep the head lower than the chest.
2. Radiographic evaluation.
a. Interpretation of cervical radiographs is more di cult.
(1) Incomplete ossi cation.
(2) Norm al anatom ical variants.
(a) Pseudosubluxation of C2–C3.
b. Spinal cord injury without radiographic abnormality (SCIWORA):
(1) Com mon in children under 10 years.
(2) Magnetic resonance im aging (MRI) is helpful in identifying the
locat ion and extent of injury.
3. Speci c injuries.
a. Occipitoatlantal instability.
(1) Most injuries are fatal.
(2) Radiographs:
(a) More than 1 mm increase in distance between odontoid tip and
basion.
(b) Power’s rat io (distance from the basion to the posterior arch of
C1 :d is t a n ce fr o m t h e o p is t h io n t o t h e a n t e r io r a rch o f C1 ).
i. Greater th an 1 is consistent with instability.
(3) Treatm ent:
(a) Occiput–C1 fusion and halo brace.
b. Je erson fracture (Fig. 22.6).
(1) Axial loading injury mechanism .
(a) Usually have an associated head injury.
(b) More com m on ly recognized due to th e increased use of
computed tom ography (CT).
(2) Radiographic nding.
(a) Widening between odontoid and lateral mass of C1.
(b) Overhang of the lateral m ass of C1 may be nor m al in a child du e
to di erential ossi cation.
(c) CT is the best for delineating fractures and helps to di erentiate
the following:
22 Pediat ric Cervical Spine Disorders 261
i. Neurocen tric syn ch on drosis (fused by 6 years).
ii. Posterior synchondrosis (fused at 5 years).
iii. Irregular ossi cation.
• Esp ecia lly t he anterior arch m ay h ave m u lt ip le ossi cat ion
centers.
(3) Treatm ent.
(a) Minerva orthosis or halo brace, depending on displacem ent or
rupture of the transverse ligament.
c. Odontoid fractures.
(1) Usually occur in children < 4 years old because synchondrosis fuses
by 6 years.
(2) Radiographs.
(a) Angulation of odontoid with displacem ent (ADI > 4.5 mm ).
(b) Flexion-exten sion radiographs.
i. May dem onstrate inst abilit y and displacem en t of th e fracture.
ii. Great caution should be taken dur ing the exion and
extension examination.
Fig . 2 2 . 6 Axia l c o m p u t e d t o m o g r a p h ic
im a g e of a Je erso n fract ure . (Fro m Imhof
H, e d . Spinal Im ag ing [Dire ct Diagn o sis
in Rad io lo g y]. St ut t ga rt , Germ any: Geo rg
Th ie m e Ve rla g ; 2 00 8 : Fig . 2 .1 6b. Re p ro duced with permission.)
262
22 Pediat ric Cervical Spine Disorders
(3) Treatm ent.
(a) Reduction by posterior translation and mild extension.
(b) Minerva or halo vest.
i. Non union (rare).
• Loss o f cont in uit y bet w een t h e od on t oid and b ody of C2 (os
odontoideum).
ii. Malu n ion (com m on).
d. Hangman’s fracture—bilateral fracture of the C2 pedicles (traumatic
spondylolisthesis of C2 on C3) (Fig. 22.7).
(1) Mechanism of injury:
(a) Extension or distraction.
(b) Com m on ly associated with facial abrasions or fractures.
(2) The majority of patients rem ain neurologically intact.
(3) Radiographs:
(a) Fractures of the pedicles and displacem ent or angulation may be
signi cant.
(4) Treatm ent:
(a) Closed reduction.
i. Posterior translation and slight extension.
(b) Minerva orthosis or halo vest.
e. Lower cervical spine injuries (Fig. 22.8).
(1) Bony injuries are less com mon in children under 10 years.
(2) Cervical dislocations should be reduced as soon as possible.
(3) Stabilization is perform ed using posterior spinous process wires and
fusion using iliac crest bon e graft.
ab
Fi g . 2 2 . 7 La t e r a l r a d i o g r a p h o f a h a n g m a n ’ s f r a c t u r e ( b i l a t e r a l C 2 p e d i c l e f r a c t u r e ) . ( F r o m I m h o f H ,
ed. Spinal Imaging [Direct Diagnosis in Radiology]. Stut tgart, Germ any: Ge org Thiem e Verlag; 2008:
Fig . 2 . 1 8 . Re p ro d u ce d wit h p e rm iss io n .)
22 Pediat ric Cervical Spine Disorders 263
a b
Fi g . 2 2 . 8 Ce rvic a l k yp h osis . (a) Lateral radiograph of a 17-year-old patient with cerebral palsy who
presented with severe thoracic lordosis and cervical kyphosis with progressive myelopathy. This patient
underwent anterior vertebrectomy and fusion and subsequent surgical procedures for correction of
his thoracic lordosis. (b) Magnetic resonance imaging of a 14-year-old boy with postlaminectomy
kyphosis and myelopathy. Anterior corpectomy and fusion were required for correction.
Sugg este d Reading
Brockm eyer DL, Ragel BT, Kestle JR. The p e d iat ric cervical spin e in st abilit y st u dy. A p ilot
study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children w ith severe traumatic injuries. Childs Nerv Syst 2012;28(5):
699–705
Jo n e s TM , An d e r s o n PA, No o n a n KJ. Pe d ia t r ic c e r v ic a l sp in e t r a u m a . J Am Ac a d Or t h o p
Surg 20 11;19(1 0): 600–611
Martus JE, Gri th TE, Dear JC, Rathjen KE. Pediatric cervical kyphosis: a comparison of
ar t h rodesis tech n iqu es. Spin e 2011;3 6(17 ):E1145 –E11 53
McKay SD, Al-Om ari A, Tomlinson LA, Dorm ans JP. Review of cervical spine anomalies in
gen etic syndrom es. Sp in e 201 2;37(5):E26 9–E2 77
23 Spinal Tumors
23.1 General Considerations
I. Eva lu at io n .
A. His t o r y:
1. Pain (localized vs. radicular) is the most common chief complaint (85% of
patients).
a. Other common presenting symptoms include motor weakness (41%) and
a palpable mass (16%).
2. Pain secondary to a spinal tumor is typically localized, progressive,
unrelenting, nonmechanical, and worse at night.
a. Patients do not have relief with rest.
3. Systemic signs and symptoms:
a. Fevers/chills.
b. Lethargy.
c. Unexplained weight loss.
4. Neurological symptoms may be present, such as weakness, sensory changes,
or bowel and bladder changes.
5. Age may help to narrow the di erential diagnosis.
a. In older patients, metastasis and multiple myeloma are more common.
6. A history of a primary tumor elsewhere in the body raises the concern of
metastases.
a. Metastatic tumors are more common than primary tumors in the spine.
Ta b l e 2 3 . 1 Co m m o n m e t as t a t ic sp in e t um o r s
Prim ary tum o r Risk facto rs
Br e a s t ca n c e r Fir s t - d e g r e e r e la t i ve
Hist o ry of incre ased e st ro g e n exposure (early m enarche, lat e
menopause, nulliparity, prolonged hormone replacement therapy)
Ra d ia t io n e xp o s u r e
Prost at e cancer Increase d age (> 4 5 years)
264
Bla d d e r o u t le t o b s t r u c t io n
Th yro id c an ce r Io d in e e xce ss / d e c ie n cy
Ra d ia t io n e xp o s u r e
Lu n g c a n c e r H i s t o r y o f s m o k i n g
Re n a l c e l l c a r c i n o m a To b a c c o u s e
23 Spinal Tumors 265
b. The spine is the most common site of bone metastases.
c. See Ta b l e 2 3 . 1 for risk factors.
B. Ph ys ic a l e xa m in at io n o f t h e sp in e s h ou ld i n clu d e p alp at io n , r a n ge o f m ot io n ,
and neurological examination.
1. Neurological examination.
a. Detailed motor examination.
b. Sensory examination.
(1) Light touch.
(2) Pinprick.
(3) Vibration.
(4) Assessm ent of long tract ndings.
(a) Re exes.
2. Physical examination of potential metastatic foci (Table 23.2).
C. Diagn os t ic st u d ie s:
1. Helpful in di erentiating tumor from infection:
a. White blood cell count (WBC), erythrocyte sedimentation rate, and
C- r e ac t ive p ro t e i n s h ou ld a ll b e e le va te d w it h in fe ct io n a n d n or m a l o r
slightly elevated with tum or.
(1) Exception is lym phom a, w hich is associated with an elevated WBC.
2. Multiple myeloma is associated with protein spikes on serum or urine
analysis.
3. Thyroid-stimulating hormone and free T4 levels are useful in identifying
thyroid disease.
4. Prostate-speci c antigen (PSA) is useful for prostate cancer.
5. Calcium and phosphate are commonly associated electrolyte abnormalities
that may need to be corrected.
6. Radiological evaluation (Table 23.3):
a. Osteolytic lesions: breast (85%), renal cell, thyroid, and lung.
b. Osteoblastic lesions: breast (15%) and prostate (Fig. 23.1).
Ta b l e 2 3 . 2 Cla ssic p hys ical e xa m n d in gs in m et as t at ic sp in e t um o r s
Prim ary t um o r Physical exam fndings
Br e a s t ca n c e r Hard, xe d, no n te nd e r bre a st m ass
Nipple re t ract io n
Skin e ryt he m a or e d e m a
Prost at e cance r Large, hard, nod ular prost at e on d ig it al re ct al e xam inat io n
Th yro id c an ce r Pa in le ss, p a lp ab le t h yro id
Lu n g c a n c e r Ba s e l i n e c h a n g e i n c o u g h
Hem opt ysis
Re n a l c e ll c a r c i n o m a Cla ssic t ria d o f h em at u ria , an k p ain , a nd a b do m in a l m as s
To b a c c o u s e
266
23 Spinal Tumors
Ta b l e 2 3 . 3 Diag nost ic im ag ing of sp ine t u m o rs
Im a g i n g s t u d y Ad v a n t a g e s D is a d v a n t a g e s
Plain
radiography
Sim ple scre e n in g m et ho d
Helpful in d iagnosis (b e nig n
vs. m alignant , ost e o lyt ic vs.
osteoblastic)
Bo n e s c a n Mo s t s e n s it i ve t o o l fo r
metastases (osteoblastic
lesio ns)
Co m p u t e d
tomography
Be s t fo r e v a lu a t in g b o n e
destruction
Im p o r t an t fo r p re o p e ra t ive
planning
Lo w s e n s i t i v i t y ( > 5 0 % o f
cancellous bone loss is needed for
radiographic identi cation of bone
destruction)
Winking owl sign
Lo w s p e c i c i t y ( c a n n o t
di erentiate fracture, infection,
and neoplasm)
In e e ct ive a s a s c r e e n in g t o o l
Mag ne t ic
resonance
im aging
High se n sitivit y, espe cially
when used with gadolinium
Provides inform at ion ab o ut
soft tissue component
Helpful in e valuating sp inal
cord com pression
Mye lo grap hy Go o d visu a lizat io n o f
epidural metastasis and cord
compression
An g io g r a p h y Se le c t ive e m b o liz a t i o n o f
the neoplasm may decrease
bleeding during surgery
Ext e n t o f c o r d c o m p r e s s io n d o e s
not consistently correlate with
symptoms or outcome
In va sive
In va sive
Fig . 2 3 . 1 Osteoblastic lesions in the L3 and L4
vert eb ra l b o d ie s.
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