Instrumentation techniques include sublaminar wiring and anterior cervical and lateral mass instrumentation. In many cases, instrumentation is now available in various sizes to accommodate young and/or small patients. Nevertheless, most plating systems are difficult to use in preadolescents. Braided sublaminar cables may pull through soft laminar bone in very young children, and should be tightened to a lower tension than in adults when used. Depending on age, bone-graft material may be harvested from morselized laminae, ribs and/or iliac crest. Surgical approach is generally dictated by the preoperative imaging studies, including MRI. Reducible subluxation injuries that are not associated with a herniated intervertebral disc are often fused posteriorly, while traumatic disc herniations and displaced or angulated vertebral fractures generally require an anterior approach. On occasion, anterior and posterior decompression and fusion is indicated. When operative intervention is required, care should be taken to expose the periosteum only at the involved levels, as unwanted spontaneous fusion may occur at any exposed level. Fusion techniques are similar to those used in adults, except that onlay bone graft alone, without instrumentation, is generally used in young children.
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