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Down Syndrome Abstract
of the Month: Dec 2000

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Safety of neck rotation for ear surgery in children with Down syndrome

Todd NW; Holt PJ; Allen AT
Laryngoscope 2000 Sep;110(9):1442-5

Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA.

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OBJECTIVE: Seek information about spinal cord safety for children with Down syndrome positioned for ear surgery.
STUDY DESIGN: Prospective consecutive patients, each serving as his or her own control.
METHODS: Somatosensory evoked potentials were recorded from 17 children who were undergoing elective otolaryngological surgery. None of the patients had neurological symptoms or physical examination findings suggesting cervical spinal cord embarrassment. Specifically, muscle tone was normal or mildly reduced globally, consistent with Down syndrome, and deep tendon reflexes were normal and not appreciably different in the upper and lower extremities. On plain lateral radiographs obtained in the neutral, flexed, and extended positions, the patients' cervical spines were normal.
RESULTS: When the anesthetized children had their necks placed in either right or left 60 degrees rotation, no significant change in somatosensory latency or amplitude was found. With more than 99.999% certainty, neurologically intact children with Down syndrome with normal plain cervical spine radiographs were not exposed to extra risks by 60 degrees neck rotation during surgery.
CONCLUSION: Patients with Down syndrome who are neurologically intact and who have normal lateral neck radiographs do not appear at great risk with neck rotation.

My comments:

The problem being addressed here is that ear surgery, such as placement of tympanostomy tubes, normally requires the extension and rotation of the head. How much rotation or extension is permissible for children with DS with normal X-rays? That is the question asked and answered here.

Somatosensory evoked potentials (SEPs) measure the speed and efficacy of neural transmissions and processing of the nerves that bring stimulation from the periphery of the body to the brain. A delay in these SEPs indicates a neurologic problem consistent with problems in the upper spinal cord, such as seen in atlanto-axial instability.(1) So, if there were a problem during rotation of the neck that caused spinal impingement on the cerival spinal cord, the SEPs would show it.

However, this study does not address the situation of children with DS and abnormal neck X-rays. The authors did recommend that perhaps SEPs could be checked on such children during the operation, and the procedure stopped or modified if the SEPs showed neurologic deficits during positioning.


  1. Pueschel SM, Scola FH. Atlantoaxial instability in individuals with Down syndrome: epidemiologic, radiographic and clinical studies. Pediatrics 1995;96:151-154.

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