Occipitocervical fusion in an infant with atlantooccipital dislocation.

Abstract

For children who survive traumatic atlantooccipital dislocation (AOD), early surgical stabilization and arthrodesis of the occipitoatlantoaxial complex is typically performed. Because of the unique and crowded anatomy of the occipitocervical junction, the creation of a fusion construct that is both safe and biomechanically sound is extremely challenging, especially in infants. We present a technical report of a patient with infantile type I AOD with gross instability, who underwent surgical stabilization consisting of occiput to C2 arthrodesis using autologous rib, augmented with bone morphogenic protein 2 (BMP-2), Mersilene suture, and Ethibond suture as "cross-connectors." The patient is a 12-month-old female infant who was involved in a high-speed motor vehicle accident and sustained a type I AOD. Definitive surgical stabilization consisting of arthrodesis from the occiput to C2 using autologous rib augmented with BMP-2, Mersilene suture, and Ethibond suture as cross-connectors was performed. There were no intraoperative complications. A follow-up cervical spine computed tomography obtained 12 weeks postoperatively demonstrated excellent occipitocervical alignment, with evidence of modest bony fusion from the occiput to C2. Neurologic examination demonstrated modest, but progressive, improvement, with partial resolution of bilateral sixth nerve palsies, and improvement in upper- and lower-extremity muscle strength and tone. Significant surgical challenges exist regarding occipitocervical fusion in infants with AOD and gross instability. This case report illustrates the successful application of BMP-2-augmented occipitocervical fusion using autologous rib, in combination with Mersilene and Ethibond suture, in the treatment of an infant with type I AOD with gross instability.