LAUSR

This comment does focus on the surgical aspects: surgery in small children is particular, but specialized anesthesia also allows complex interventions in this patient group. Closed reduction of the spinal dislocation might be achieved, but in cases with a complete disruption of the ligamentous complex the spine does not show any intrinsic stability. Transient fixation of the head with sandbags can be useful. The surgical approach follows the same principles as in adults. The challenges start with the bone. The skeleton is very small, the anatomical structures are tiny. The bone is very soft. On the other hand, in children the head is disproportionately big and heavy, the mechanical demands are high, contrasting problems need to be solved. The surgical strategy for the treatment of subaxial CS disruptions with a combined approach appears necessary in order to overcome the mechanical instability most reliably— as all shear forces can be neutralized. The use of small plates from the maxillofacial armamentarium (like in this case) or from hand surgery might be the solution [1–4]. A posterior tension banding with sutures seems sufficient [2, 9], alternatively wiring and plate/screw fixation has been described [3, 5, 6]—possibly ending in breakage over time [5]. So far this approach as presented here appears feasible and in addition with an external support the stability can be maintained until the injury is heeled. Whether there is a necessity for a formal fusion with bone graft remains open. In a case of a 3-week-old child a noninstrumented posterior fusion was performed with BMPII [7]; in the presented case an allograft was used after removal of the disc, similar to Li et al. who in addition performed a posterior suturing and bone grafting [4]. In the two cases reported by Rooks et al. the detailed surgical techniques are not mentioned [8]. The injuries in all presented cases show a uniform pattern with a disruption of the growth plate (Salter I). Once In a regular frequency, case reports on this very sad topic are published. Fortunately, cervical spine injuries with spinal cord involvement in young children are rare (as far as they come to attention). It appears very likely that a spine surgeon does see this kind of injury in the very young child only once during his professional career. Therefore, it appears meaningful to collect the experience available and try to find a “conclusion” that can be helpful for someone who is faced with this kind of problem. The presented case [1] is well documented and brings to consideration the challenges of surgical treatment. An own case of a 1.5-year-old child treated over 10 years ago did not only represent a diagnostic but also a surgical challenge— with a “successful” outcome regarding the surgical technical aspects, but continuing complete tetraplegia [2].