SPINE Volume 26, Number 7, pp 825–829
©2001, Lippincott Williams & Wilkins, Inc.
A Technique of Occipitocervical Arthrodesis in
Children Using Autologous Rib Grafts
Max W. Cohen, MD, Denis S. Drummond, MD, John M. Flynn, MD, Stephan G. Pill, MS, PT,
and John P. Dormans, MD
Study Design. Description of an operative technique
with an illustrative case report.
Objectives. The technique is presented to provide an
alternative to iliac crest graft procedures for achieving
occipitocervical fusion in children. This technique is par-
ticularly useful in children with instability after extensive
decompression or laminectomy and in children with a
large protuberant occiput.
Summary of Background Data. The majority of tech-
niques previously described for occipitocervical fusion in
children rely on corticocancellous iliac crest autograft.
Results generally have been promising; however, it can
be difficult to harvest enough graft to span large defects
after extensive decompression or to contour an iliac crest
graft to a protuberant occiput. Structural rib autograft is
superior in terms of availability and its unique and mod-
ifiable contour. Theoretical benefits of rib graft include
superior strength and lower donor site morbidity.
Methods. The surgical technique is described. A case
of a 2-year-old boy with Down’s syndrome and myelop-
athy secondary to cervical instability is reviewed.
Results. The patient underwent occipitocervical arth-
rodesis using the technique described. The child made a
full neurologic recovery, and at the 2-years follow-up
evaluation, the graft had incorporated and the spine was
stable.
Conclusion. A technique of occipitocervical arthrode-
sis in children is described using autologous rib graft.
This procedure was designed to span large defects or to
deal with a large protuberant occiput; however, it is also
useful for less demanding cases and may offer several
advantages compared with procedures relying on iliac
crest graft. [Key words: atlanto-occipital joint, arthrodesis,
child Down’s syndrome, ribs spinal fusion] Spine 2001;26:
825–829
Occipitocervical fusion is rarely done in children, but it is
occasionally indicated in the pediatric patient with cer-
vical instability caused by a variety of congenital or ac-
quired conditions. Several techniques have been de-
scribed, most using corticocancellous graft harvested
from the iliac crest. Fixation of the graft generally has
been accomplished with rigid wiring or heavy suture
combined with various methods of postoperative immo-
bilization.2,3,5,7,8,14 Results generally have been favor-
able; however, these techniques are not always applica-
ble when the arthrodesis must span multiple levels
From the Division of Orthopaedic Surgery, Children’s Hospital of Phil-
adelphia, Philadelphia, Pennsylvania.
Acknowledgment date: February 8, 2000.
First revision date: May 10, 2000.
Acceptance date: June 23, 2000.
Device status category: 1.
Conflict of interest category: 12.
brought about by extensive laminectomy or decompres-
sion. In addition, some patients have a difficult-shaped
occiput rendering a relatively straight iliac crest graft
suboptimal. This report describes a technique for occipi-
tocervical fusion using autologous rib grafts, specifically
designed for spanning large defects and for patients with
a large or odd-shaped skull. The rib is an ideal structural
material for these difficult cases. The shape of the graft
can be modified by the choice of rib and by moving the
resection from the flatter posterior to the more curved
anterior portion of the rib. Children’s ribs are quite plas-
tic and can be molded after harvest to fine-tune the lor-
dotic contour of the graft. This should be limited to avoid
compromising the structural integrity of the rib. The
unique and modifiable shape of rib allows optimal con-
tact between the graft and recipient bed. In contrast to
iliac crest graft, procurement can be accomplished
through a single surgical field. Finally, rib is strong,
readily available, provides low donor site morbidity, and
regenerates rapidly in children.
Operative Technique
After intubation in the supine position, a halo ring is applied.
Subsequently, the patient is carefully positioned prone, and the
halo is secured to the operating table using the Mayfield posi-
tioning frame. The alignment of the occiput and cervical spine
is confirmed with a lateral radiograph. The positioning, halo
application, reduction, and all subsequent surgery is performed
with somatosensory and motor-evoked potential monitoring.
The posterior thorax is included in the surgical field for harvest
of the autogenous rib graft. The exposure extends from the
occiput to the second cervical vertebra or to the first vertebra
that is both below the level of instability and that has an intact
posterior arch. Particular care is taken to limit the lateral dis-
section to avoid damage to the vertebral arteries.
A high-speed drill is used to make four burr holes through
both cortices of the occiput. The holes are aligned transversely
with two on each side of the midline and are placed caudal to
the transverse sinuses. A strong osseous bridge is left between
each pair of holes (Figure 1a). The area to be spanned by the rib
graft is evaluated for both overall length and sagittal contour.
The caudal extent of the arthrodesis is determined by the pres-
ence or absence of a previous laminectomy, congenital anom-
alies, or the level of the instability.
The graft harvest is accomplished through an oblique inci-
sion is made over the rib intended for harvest. The specific rib
as well as the portion of it to be harvested is determined by the
length and the optimal shape required to span the planned
arthrodesis (Figure 1b). The muscles of the posterior chest wall
are split in line with the incision down onto the thoracic cage.
825
826 Spine • Volume 26 • Number 7 • 2001
Figure 1. A, Four burr-holes are placed into the occiput in transverse alignment, with two on each side of the midline, leaving a strong
osseous bridge between the two holes of each pair. B, Cranially,16-gauge wire is passed through each burr hole pair. Caudally, wires are
passed under the lamina on each side of the midline at the second cervical vertebra or at the first vertebra that is both below the level
of instability and that has an intact posterior arch. The rib graft is secured into place by twisting the wires.
The periosteum overlying the rib is incised and circumferen-
tially dissected and elevated. The graft is removed by cutting it
proximally and distally with a rib cutter. Adequate rib should
be harvested so that enough is available for both structural and
moralized graft. After the graft harvest, the exposed pleura is
inspected, and its integrity is confirmed. The wound is flooded
with irrigation fluid, and the lungs are hyperinflated. If no air
leaks are observed, the wound is closed in layers. If there has
been an inadvertent injury to the pleura, this is repaired, and a
decision is made concerning the need for thoracostomy
drainage.
Two full-thickness structural grafts are precisely contoured
to the shape of the required arthrodesis site. On each side of the
midline, 16-gauge wire is passed under the strong osseous
bridge between burr holes. The wires are secured for later fix-
ation of the graft. Alternatively, braided cable can be used in
place of wire. For patients who are very small or who have thin
bone of poor quality, #5 Mersilene suture can be used to de-
crease the risk of the wire or cable cutting out. Distal purchase
is accomplished with wire, cable, or suture passed under the
lamina of the caudal vertebra, one on each side of the midline.
The structural grafts then are positioned in the arthrodesis site
and, under radiographic control, secured into place by subse-
quently twisting and cutting the previously placed wires (Figure
1c). Reduction and alignment of the occiput and spine can be
controlled by positioning of the head with the halo frame, by
adjusting the contour of the graft, and, to a lesser extent, by
appropriate tightening of the wires. After acceptable alignment
has been confirmed, moralized rib autograft is packed into the
arthrodesis site, and the wound is closed in layers. The Halo
vest is applied and maintained for 8 –12 weeks after surgery. A
chest radiograph is taken in the recovery room to detect an
occult pneumothorax.
Case Report
The patient is 2-year-old boy with Down’s syndrome who was
admitted to the hospital with a 24-hour history of being unable
to walk or move his upper extremities. Three months before
admission, he experienced a minor trauma and developed a
torticollis to the right that resolved. He also was noted to have
a decrease in his ability to walk and use his upper extremities
during the past 2 months. On presentation, he had a marked
quadriparesis and was unable to move his extremities against
gravity. Respiratory efforts were noted to be weak. Radio-
graphs of the cervical spine revealed marked atlantoaxial sub-
luxation with a decrease in the space available for the cord
(Figure 2a). Magnetic resonance imaging again demonstrated
subluxation of C1 on C2 with compression and edema of the
spinal cord at this level (Figure 2b). The MRI was repeated with
mild extension of the cervical spine, and the subluxation was
noted to reduce, relieving the cord compression. He was started
on Dexamethasone (4 mg IV every 6 hours) to control spinal
cord edema and electively intubated for hypoventilation and an
increasing PCO2. A halo vest was applied in slight extension,
and reduction of C1 on C2 was verified with a lateral radio-
graph. He was monitored in the intensive care unit and main-
tained on ventilator support and intravenous steroids. Defini-
tive surgical intervention was delayed to allow for reduction in
spinal cord edema.
Five days after admission, he was taken to the operating
room for an occipitocervical fusion using the technique de-
scribed above (Figure 2c, 2d). The decision to extend the arth-
rodesis to the occiput was made because of the high complica-
tion rate reported with posterior cervical arthrodesis in
children with Down’s syndrome.10 In addition, Tredwell et al13
have demonstrated the common occurrence of atlantooccipital
instability along with atlantoaxial instability in this patient
population. The patient was extubated 9 days after the arthro-
desis, and the halo vest was discontinued at 10 weeks when
there was radiographic evidence of fusion. The child made a
full neurologic recovery, and at the 2-year follow-up evalua-
tion, the graft had incorporated, and the spine was stable in
flexion and extension.
 Occipitocervical Arthrodesis Using Rib Grafts • Cohen et al 827

Figure 2. A, Boy with Down’s

syndrome and myelopathy. Lat-
eral radiograph demonstrating
subluxation of C1 on C2. B, Post-
operative lateral radiograph after
reduction and occiput to C2 fu-
sion using autologous rib graft. C,
Lateral radiograph taken 2 years
after surgery demonstrating in-
corporation of rib grafts.

Discussion ing the same technique. Results have been promising;

The authors of the present study have previously re-
ported on 16 consecutive children who underwent an
occipitocervical arthrodesis using autologous iliac crest
graft.2 Since reporting on these patients, the authors have
performed approximately 20 additional procedures us-
however, on several younger patients it was difficult to
obtain enough graft material. In infants, the iliac crest is
relatively small in comparison to the head and spine. When
multiple levels must be spanned after extensive decompres-
sion, there can be a shortage of iliac crest graft.
828 Spine • Volume 26 • Number 7 • 2001
Figure 3. Adolescent girl with spina bifida, controlled hydroceph-
alus, and spinal stenosis of the upper cervical spine. Because of
progressive myelopathy, extensive decompression and arthrode-
sis was done from the occiput to C4. Structural rib graft was used
to span the protuberant occiput and the extensive laminectomy
defects. Lateral radiograph 1 year after surgery showing incorpo-
ration of the rib grafts. Heavy suture was used to secure the grafts
because of the patient’s poor bone quality.
Iliac crest graft also can be suboptimal in patients with
a large protuberant occiput. Hydrocephalus, for exam-
ple, can alter the relation of the occiput to the cervical
vertebrae, placing the spine relatively anterior to the
back of the skull (Figure 3). If a relatively straight iliac
crest graft is fixed proximally to the occiput and distally
to the caudal vertebra, the intervening segments of the
spine will lie at a distance from the graft. Rib has unique
curvature that can be customized to allow optimal con-
tact with the recipient bed. This is accomplished by se-
lecting a rib with an appropriate contour, by moving the
resection from the flatter posterior portion to the more
curved anterior portion of the rib.
Autogenous rib has several practical and theoretical
advantages over iliac crest as a graft for occipitocervical
fusion. Rib provides an abundant source of material, and
it regenerates rapidly in children. Procurement is predict-
able because rib can easily be resected en bloc, resulting
in a more reliable corticocancellous structure compared
with grafts taken from the iliac crest. Grafts applied to
the occipitocervical junction are subjected to multiplanar
loads including flexion– extension, axial rotation, and
lateral bending.16 The circumferentially intact cortex of
rib makes it better suited to withstand these multiplanar
loads.
A major limitation of iliac crest graft is donor site
morbidity, the incidence of which exceeds 25% in some
series.1,9,12 The principle objection to using rib as a graft
source has been the potential for serous donor site mor-
bidity, including pneumothorax and intercostal neural-
gia. Whitaker et al15 reported a high rate of pneumotho-
rax complicating rib harvest used for craniofacial
reconstruction in a multi-institutional review. This num-
ber approached 30% at some participating centers. Lau-
rie et al6 reported on a similar patient population with a
9% incidence of this complication. These investigators
also reported a 6.8% incidence of persistent dysesthetic
chest pain. Several small subsequent series reported a 3%
and 0% incidence of pneumothorax and no cases of
chronic chest wall pain.4,11 Typically, the authors of the
present study have not experienced complications from
rib harvest, even when multiple ribs are removed in sco-
liosis patients after thoracoplasty. Recently, Sawin et al9
reviewed a heterogenous group of 600 patients undergo-
ing cervical spine fusion. Three hundred patients under-
went rib harvest and posterior cervical arthrodesis. The
remaining patients underwent iliac crest harvest (248 for
an anterior cervical arthrodesis and 52 for posterior ar-
throdesis). The rib harvest group had a 3.7% complica-
tion rate and 0% incidence of pneumothorax or chest
wall pain. Iliac crest morbidity occurred in 25.3% of the
patients in this group. Fusion occurred in 98% of the rib
graft and 94% of the posterior iliac crest constructs,
leading these authors to conclude that autogenous rib is
superior to iliac crest for posterior cervical arthrodesis in
terms of donor site morbidity and rate of osseous union.
The technique described in this report was designed to
deal with a difficult-shaped skull or to span laminectomy
defects in children requiring occipitocervical arthrodesis.
The procedure also should be useful in less demanding
situations and may offer several advantages compared
with iliac crest procedures in terms of donor site morbid-
ity, graft strength, and rate of fusion.
Key Points
● Rib has a unique and modifiable contour that
makes it ideal for posterior occipitocervical arthro-
desis in children.
● Rib is strong, readily available, and provides low
donor site morbidity.
● Structural rib graft is particularly useful when
spanning large laminectomy defects or to deal with
a protuberant occiput in children requiring occipi-
tocervical arthrodesis.
References
1. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor
site morbidity. A statistical evaluation. Spine 1995;20:1055– 60.
2. Dormans JP, Drummond DS, Sutton LN, et al. Occipitocervical arthrodesis
in children. A new technique and analysis of results. J Bone Joint Surg 1995;
77A:1234 – 40.
3. Georgopoulos G, Pizzutillo PD, Lee MS. Occipitoatlantal instability in chil-
dren. A report of five cases and review of the literature. J Bone Joint Surg
1987;69A:429 –36.
4. Kline RM, Wolfe S. Complications associated with the harvesting of cranial
bone grafts. Plast Reconstr Surg 1995;95:5–13.
5. Koop SE, Winter RB, Lonstein JE. The surgical treatment of instability of the
upper part of the cervical spine in children and adolescents. J Bone Joint Surg
1984;66A:403–11.
6. Laurie SW, Kaban LB, Mulliken JB, et al. Donor-site morbidity after har-
vesting rib and iliac bone. Plast Reconstr Surg 1984;73:933– 8.
 Occipitocervical Arthrodesis Using Rib Grafts • Cohen et al 829

7. Letts M, Slutsky D. Occipitocervical arthrodesis in children. J Bone Joint 15. Whitaker LA, Munro IR, Salyer KE, Jet al. Combined report of problems and
Surg 1990;72A:1166 –70. complications in 793 craniofacial operations. Plast Reconstr Surg 1979;64:
8. Rodgers WB, Coran DL, Emans JB, et al. Occipitocervical fusions in chil- 198 –203.
dren. Retrospective analysis and technical considerations. Clin Orthop 1999; 16. White AA, Panjabi MM. The clinical biomechanics of the occipitoatlanto-
364:125–33. axial complex. Orthop Clin North Am 1978;9:867–78.
9. Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of fusion
rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in
posterior cervical fusions. J Neurosurg 1998;88:255– 65.
10. Segal LS, Drummond DS, Zanotti RM, et al. Complications of posterior Address reprint requests to
arthrodesis of the cervical spine in patients who have Down’s syndrome.
J Bone Joint Surg 1991;73A:1547–54. Denis S. Drummond, MD
11. Skouteris CA, Sotereanos GC. Donor site morbidity following harvest of Division of Orthopaedic Surgery
autogenous rib grafts. J Oral Maxillofac Surg 1989;47:808 –12.
12. Summers BN, Eisenstein SM. Donor site pain from the ilium: a complication
Children’s Hospital of Philadelphia
of lumbar spine fusion. J Bone Joint Surg 1989;71B:677– 80. 2nd Floor Wood Building
13. Tredwell SJ, Newman DE, Lockitch G. Instability of the upper cervical spine 34th and Civic Center Blvd
in Down’s syndrome. J Pediatr Orthop 1990;10:602– 6. Philadelphia, PA 19104
14. Wertheim SB, Bohlman HH. Occipitocervical fusion. Indications, technique,
and long-term results in 13 patients. J Bone Joint Surg 1987;69A:833– 6.