TECHNICAL NOTE

Surgical Stabilization of C2–C3 Dislocation in Children Younger Than Eight Years

Claudio A. Fernández,^*María Gabriela Miranda,^*^,** María Emilia Moreiro Varela^*,*^*

^*School of Medical Sciences, Universidad Nacional de La Plata, Buenos Aires, Argentina

^**Orthopedics and Traumatology Service, Hospital de Niños “Sor María Ludovica”, La Plata, Buenos Aires, Argentina

ABSTRACT

Introduction: Traumatic dislocations of the C2–C3 segment in children are associated with a high risk of neurological injury and even death due to their inherent instability. Once the diagnosis is confirmed, surgical treatment is indicated. We describe a double-fixation technique performed during the same surgical procedure. Initially, reduction and primary stabilization of the C2–C3 segment are achieved using sublaminar cerclage or transfixation with a nonabsorbable suture. Subsequently, osteosynthesis with facet screws is performed. In younger children, minifragment screws and a custom-made plate are used, whereas in older children, standard adult instrumentation can be employed; in both cases, fixation follows the Magerl technique. Conclusion: The combined and complementary use of two stabilization techniques provides greater intraoperative safety and yields stable long-term outcomes.

Keywords: Children; C2-C3 dislocation; surgical stabilization.

Level of Evidence: IV

Estabilización quirúrgica de la luxación de C2-C3 en niños menores de 8 años

RESUMEN

Introducción: Las luxaciones traumáticas del segmento C2-C3 en niños conllevan un alto riesgo de daño neurológico e incluso de óbito debido a su inestabilidad. Una vez que se confirma el diagnóstico, el tratamiento indicado es la cirugía. Se detalla una técnica de doble fijación efectuada en el mismo acto quirúrgico. En primer lugar, se practica la reducción y la estabilización primaria mediante un cerclaje sublaminar o transfixión con hilo no absorbible del segmento C2-C3. Posteriormente, se realiza la osteosíntesis con tornillos facetarios. En niños pequeños, empleamos tornillos para minifragmentos y una placa ad hoc, en tanto que, en niños mayores, se puede utilizar material de adultos, en ambas situaciones, según la técnica de Magerl. Conclusión: El uso combinado y complementario de dos técnicas de estabilización proporciona más seguridad intraoperatoria y resultados estables en el tiempo.

Palabras clave: Niños; luxación de C2-C3; estabilización quirúrgica.

Nivel de Evidencia: IV

INTRODUCTION

According to statistics from the National Pediatric Trauma Registry of the United States, traumatic injuries of the cervical spine in children account for 1.5% of all trauma admissions.¹ This represents 60 to 80% of spinal traumatic conditions, including fractures, ligamentous injuries, and combined lesions.² These injuries are more prevalent in males, and the etiology includes, in decreasing order of frequency, traffic accidents, falls, sports-related activities, non-accidental trauma, and labor dystocia.^3-7 Upper cervical spine injuries are twice as frequent as those affecting the subaxial segment, following a bimodal distribution at 3 and 16 years of age. However, dislocations are five times more common, with a reported prevalence ranging from 25% to 40%.^1,2 Approximately one third of these children present partial or complete neurological involvement associated with SCIWORA (Spinal Cord Injury Without Radiological Abnormalities), with a reported frequency between 4.5% and 35%.² Mortality rates are significant in young children with complete neurological deficits, reaching up to 17%.¹ Several anatomical and physiological factors confer increased susceptibility to trauma in this region, including tissue hyperlaxity, particular configuration of the occipitoatlantal joint, reduced muscle tone, disproportion between cervical and cephalic volumes, and decreased inclination of the articular facets. The C2-C3 segment, which represents the transition zone between the mobile craniocervical and subaxial regions, is particularly prone to fractures, pathological sub-luxations, and dislocations, a phenomenon known as the fulcrum effect.²

The objective of this article is to describe the surgical strategy and technique used for the stabilization of C2-C3 dislocations in children younger than 8 years of age.

SURGICAL TECHNIQUE

The patient is placed in the prone position on a silicone mat with lateral supports. The arms are extended and secured to the trunk, and the head is positioned on a silicone headrest to protect pressure-sensitive areas. This position is secured with adhesive tapes fixed to the operating table, and the upper limbs are gently pulled caudally from the shoulders to improve exposure of the cervical region. The iliac crest must remain free and accessible for harvesting autologous bone graft. The entire surgical procedure is supervised by a neurophysiologist using multimodal intraoperative monitoring.

Once the surgical field has been prepared, the affected osseous segment is confirmed using an image intensifier, and the skin is marked with indelible ink. A posterior approach is used. After incision of the skin and fascia, the spinous processes of the axis and C3 are palpated to minimize the extent of surgical exposure. Subperiosteal dissection is extended to the articular processes, which is an important step to prevent unnecessary extension of the fusion area. The dislocation is reduced with extreme care using Backhaus forceps. When reduction is difficult, a small dissector or periosteal elevator may be used to mobilize the facet joints. Primary stabilization is achieved with a suture composed of two strands of non-absorbable Prolene® 2.0 using one of two techniques: 1) double sublaminar cerclage at the C2-C3 level, similar to the Brooks and Jenkins technique but applied at an infradjacent level (Figure 1) 8 or 2) osseous transfixion using a 2.5 mm diameter drill at the spinolaminar junction of the axis. The suture is passed through the drilled tunnel and then curved beneath the spinous process of C3 without crossing the midline (Figures 2 and 3).

Both techniques provide sufficient stability to prevent any inadvertent movement during the remainder of the procedure. Osteosynthesis is then performed using C2-C3 facet screws with a diameter of 3.5 mm and standard adult instrumentation or, in patients with very small anatomical dimensions, 2.2 mm diameter mini-fragment screws, combined with a custom plate, according to the Magerl technique. Final radiographic control is obtained, followed by placement of an autologous iliac crest bone graft impregnated with vancomycin. Postoperatively, the patient is fitted with a soft cervical collar or a Philadelphia collar for a period of 8 weeks.

DISCUSSION

Dislocations of the C2-C3 segment are rare and only sporadically mentioned in the literature. Even in publications based on case series derived from database searches in PubMed and Excerpta Medica Database (EMBASE), there are no reports specifically describing C2-C3 dislocation.^1,2,9,10 We identified nine published cases, whose main common feature was marked therapeutic heterogeneity (Table).

Several authors have reported their experiences. Jones and Hensinger performed C2-C3 wire cerclage in a 20-month-old child.³ Sakayama et al. used an identical technique combined with halo vest immobilization for 8 weeks.¹¹ Hamoud and Abbas performed a transosseous suture using absorbable material through the spinous process of the axis, linking it to that of C3 in a 23-month-old child. They did not add arthrodesis and prescribed immobilization with a Philadelphia collar for 8 weeks.¹² Sellin et al. stabilized the C2-C3 segment using facet screws in an adolescent.¹³ O’Neill et al. performed reduction under general anesthesia and indicated halo vest immobilization in a 6-year-old child.¹⁴ Finally, Zeng et al. used facet osteosynthesis with screws and minifragment plates, combined with autologous bone grafting, in an 8-year-old child.¹⁵ Chen et al. placed small-fragment osteosynthesis material in the subaxial spine of a 22-month-old child.¹⁶ We agree with other authors who recommend selecting the type of osteosynthesis based on tomographic measurement of the facet joints.¹⁷

The technique used in our cases follows a defined surgical strategy consisting of the following steps: 1) limited exposure of the affected segment; 2) reduction; 3) primary stabilization using non-absorbable suture material; and 4) facet osteosynthesis combined with bone grafting for definitive segmental stabilization.

Due to the lack of specific pediatric instrumentation, osteosynthesis systems designed for minifragment fixation were used. These systems are commonly employed in adult surgery of the long bones of the hand or foot. This approach was applied in a 9-month-old girl and a 4-year-old boy. In an 8-year-old patient, osteosynthesis material designed for adults was used. Double sublaminar cerclage at the C2-C3 level was performed in a 9-month-old girl with a lacerating soft tissue injury that facilitated passage of the suture material (Figure 1). However, for primary stabilization purposes, transfixion suturing through the spinous process of the axis, with the suture curved beneath the C3 spinous process and secured with an appropriate knot, is sufficient and safe. Regardless of the treatment modality, all authors reported stable long-term outcomes. Finally, McGrory and Klassen reported extension of the fusion mass in 38 percent of 42 children who underwent cervical spine arthrodesis for fractures and dislocations.¹⁸

In summary, we consider C2-C3 dislocation to be an unstable injury with a potential risk of neurological compromise and death. The sequential and combined use of two stabilization techniques provides greater intraoperative safety and yields stable outcomes over time.

REFERENCES

1. Patel JC, Tepas JJ III, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 2001;36(2):373-6. https://doi.org/10.1053/jpsu.2001.20720

2. Gopinathan NR, Viswanathan VK, Crawford AH. Cervical spine evaluation in pediatric trauma: A review and an update of current concepts. Indian J Orthop 2018;52(5):489-500. https://doi.org/10.4103/ortho.IJOrtho_607_17

3. Jones ET, Hensinger RN. C2-C3 dislocation in a child. J Pediatr Orthop 1981;1(4):419-22. https://doi.org/10.1097/01241398-198112000-00011

4. Eljure G, Tello CA, Corrado R, Remondino R, Galaretto E, Noel M, et al. Parto distócico asociado a luxofractura cervical y compromiso neurológico. Reporte de cuatro casos. Rev Asoc Argent Ortop Traumatol 2015;80(3):207-16. Available at: https://www.scielo.org.ar/scielo.php?pid=S1852-74342015000300010&script=sci_arttext

5. Fernández CA, Miranda MG, Moreiro ME. Una discusión sobre la línea espinolaminar de Swischuk: revisión bibliográfica. Rev Asoc Argent Ortop Traumatol 2024;89(4):393-402. https://doi.org/10.15417/issn.1852-7434.2024.89.4.1897

6. Fernández CA, Moreiro ME, Miranda MG. Instrucción ortopédica de posgrado - imágenes: presentación del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):592-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1827

7. Fernández CA, Moreiro ME, Miranda MG. Instrucción ortopédica de posgrado - imágenes: resolución del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):692-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1828

8. Vaccaro AR, Todd JA. Posterior cervical arthrodesis and instrumentation. In: Vaccaro AR, Todd JA. Spine Surgery. 3.ª ed. New York: Thieme Medical Publishers; 2016. p. 16-40.

9. Zhang JK, Hongsermeier-Graves N, Savic B, Nadel J, Sherrod BA, Brockmeyer DL, et al. Pediatric cervical spine trauma: a narrative review. Clin Spine Surg 2024;37(9):416-24. https://doi.org/10.1097/BSD.0000000000001708

10. Haddad E, Al Khoury Salem H, Dohin B. Diagnosis and treatment of cervical spine injuries in children. Orthop Traumatol Surg Res 2024;110(1S):103762. https://doi.org/10.1016/j.otsr.2023.103762

11. Sakayama K, Kidani T, Matsuda Y, Sugawara Y, Shibata T, Yamamoto H. A child who recovered completely after spinal cord injury complicated by C2-3 fracture dislocation: case report. Spine (Phila Pa 1976) 2005;30(10):E269-71. https://doi.org/10.1097/01.brs.0000162533.02807.c9

12. Hamoud K, Abbas J. A new technique for stabilization of injuries at C2-C3 in young children. Injury 2014;45(11):1791-5. https://doi.org/10.1016/j.injury.2014.05.027

13. Sellin JN, Shaikh K, Ryan SL, Brayton A, Fulkerson DH, Jea A. Clinical outcomes of the surgical treatment of isolated unilateral facet fractures, subluxations, and dislocations in the pediatric cervical spine: report of eight cases and review of the literature. Childs Nerv Syst 2014;30(7):1233-42. https://doi.org/10.1007/s00381-014-2395-6

14. O’Neill C, Wenzel A, Walterscheid Z, Carmouche J. Distinguishing pseudosubluxation from true injury: a case of C2-3 and C3-4 subluxation in a pediatric patient. J Am Acad Orthop Surg Glob Res Rev 2021;5(12). https://doi.org/10.5435/JAAOSGlobal-D-20-00238

15. Zeng J, Jiang H, Zhuo Y, Xu Y, Deng Z. A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury. Medicine (Baltimore) 2022;101(30):e29717. https://doi.org/10.1097/MD.0000000000029717

16. Chen Y, Wang X, Chen D, Liu X. Surgical treatment for unilateral cervical facet dislocation in a young child aged 22 months: a case report and review of the literature. Eur Spine J 2013;22(Suppl 3):S439-42. https://doi.org/10.1007/s00586-012-2590-7

17. Sotomayor HE, Remondino R, Tello C, Galaretto E, Francheri I, Bersusky E, et al. Instrumentación cervical en pacientes menores de 10 años. Rev Asoc Argent Ortop Traumatol 2017;82(3):220-3. https://doi.org/10.15417/616

18. McGrory BJ, Klassen RA. Arthrodesis of the cervical spine for fractures and dislocations in children and adolescents: a long-term follow-up study. J Bone Joint Surg Am 1994;76(11):1606-16. https://doi.org/10.2106/00004623-199411000-00003

M. G. Miranda ORCID ID: https://orcid.org/0000-0003-4949-9407

M. E. Moreiro Varela ORCID ID: https://orcid.org/0009-0000-5590-9738

Received on March 10th, 2025. Accepted after evaluation on June 2nd, 2025 • Dr. Claudio A. Fernández • claudioalfredofernandez619@gmail.com • https://orcid.org/0000-0003-2350-3885

How to cite this article: Fernández CA, Miranda MG, Moreiro Varela ME. Surgical Stabilization of C2–C3 Dislocation in Children Younger Than Eight Years. Rev Asoc Argent Ortop Traumatol 2026;91(1):65-70. https://doi.org/10.15417/issn.1852-7434.2026.91.1.2140

Article Info

Identification: https://doi.org/10.15417/issn.1852-7434.2026.91.1.2140

Published: February, 2026

Conflict of interests: The authors declare no conflicts of interest.

License: This article is under Attribution-NonCommertial-ShareAlike 4.0 International Creative Commons License (CC-BY-NC-SA 4.0).