Characterizing pediatric cervical fusion in the modern era: indications, complications, and fusion rates.

Abstract

Objective: Cervical fusion within the pediatric population presents unique challenges, because pediatric cervical fixation demands careful consideration of anatomical size, physiological differences, and significant prospective growth potential for young patients. In the present systematic review, the authors outline the indications for cervical fusion, summarize patient outcomes in the pediatric population, and characterize the various cervical fixation surgical techniques.

Methods: A retrospective literature review of pediatric cervical fusion was conducted in June 2024 via PubMed, in accordance with PRISMA guidelines and using appropriate search syntax and evidence schemes. The initial literature search yielded 1107 articles, with 259 articles undergoing a full-text review. Inclusion criteria included studies examining pediatric populations (age ≤ 18 years) requiring cervical spine surgical fixation between 2000 and 2024. Studies in which patients with cervical pathology were not surgically treated, those examining primarily adult populations > 18 years old (n = 504), case reports (n = 150), and non-English studies (n = 96) were excluded. Outcomes consisted of demographic variables, fusion rates, bone morphogenetic protein (BMP)/graft material used, and complications.

Results: In total, 106 studies between 2000 and 2024 examining 2086 patients were included in the review. The most common surgical indications across all studies included atlantoaxial instability (n = 49, 48.5%). Most studies reported cases involving occipitocervical (OC) junction pathology (n = 74, 69.8%) and using iliac crest autograft (n = 53, 50.0%) and rib autograft (n = 28, 26.4%). Allografting was used in 25 studies (23.9%) and BMP was used in 26 studies (24.5%). Overall, the fusion rate for pediatric patients undergoing cervical fusion was 95.8%, with OC fusion having comparable fusion rates (0.95 ± 0.02) to those without OC junction involvement (0.96 ± 0.01, p = 0.703). The overall complication rate was 14.9%. There were similar rates of complications compared to studies with and without OC fusion (OC: 0.15 ± 0.18, non-OC: 0.13 ± 0.17; p = 0.075).

Conclusions: Despite efforts to characterize the comparative advantages of different immobilization techniques, such as screw constructs versus wiring, and the use of bone graft materials including BMP, a comprehensive understanding of outcomes remains elusive. The overall fusion rate observed in the analyzed cohort aligns with prior research, yet complications persist, with a notable proportion necessitating reoperation or revision in those with OC pathology. Although the incorporation of BMP alongside autograft and allograft materials remains relatively uncommon, the potential benefits warrant further research, with longitudinal follow-up of fusion rates.