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An 11-year-old male complains of one year duration of neck pain. He denies any recent trauma. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. Neutral and flexion radiographs are shown in Figures A and B. A sagittal CT scan is shown in Figure C with a coronal reconstruction shown in Figure D. What is the most appropriate treatment?
PT to strengthen the dynamic stabilizers of the neck
Soft collar wear during any athletic activities
Cessation of all contact sports with no surgical intervention
Posterior C1-C2 fusion
Anterior C1-2 fusion
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The clinical presentation and imaging studies are consistent with os odontoideum with neurologic deficits. A posterior C1-C2 fusion is the most appropriate treatment.
Whether os odontoideum is congenital or the residual of a traumatic process is controversial. Most authors support a post-traumatic etiology; however, some evidence exists to support a congenital origin. Asymptomatic patients may be managed with cessation of contact sports alone. Neurologic findings and widened ADI are both indications for a posterior C1-C2 fusion.
Reilly et al. performed a study to evaluate transarticular screw use in pediatric patients with C1-C2 instability. They used a transarticular constuct in 9 patients with os odontoideum and 3 patients with Down Syndrome. They found, although vertebral size and congenital anomalies may make screw positioning challenging, the technique allows adequate fixation and is especially beneficial in the absence of a complete posterior arch of C1. They found high fusion rate in mid-term followup.
Sankar et al. designed a study to address the controversy over the etiology of os odontoideum. Their data supports two separate etiologies for the os odontoideum: post-traumatic and congenital.
Figure A and B are flexion extension views that show os odontoideum with associated dynamic atlantoaxial instability. Figure C and D are CT images that should os odontoideum. Notice the rounded sclerotic edges that differentiate this condition from an acute fracture.
Answer 1,2,3: Nonoperative modalities would not be appropriate in this patient with neurologic deficits.
Answer 5: An anterior C1-2 fusion is not a viable procedure due to the osseous anatomy at this level.
Reilly CW, Choit RL
J Pediatr Orthop. 2006 Sep-Oct;26(5):582-8.PMID: 16932095 (Link to Abstract)
Sankar WN, Wills BP, Dormans JP, Drummond DS
Spine. 2006 Apr;31(9):979-84. PMID: 16641773 (Link to Abstract)
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