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Background: The paediatric craniocervical junction has anatomical, physiological and biomechanical properties that make this region unique from that of the adult spine, vulnerable to injury, and contribute to the complexity of management. Traditionally, onlay fusion with external halo immobilisation has been used. Instrumented fusion offers intra-operative reduction and immediate stability. Methods: A retrospective review of a single surgeon’s prospectively maintained database was conducted for all cases of paediatric patients that had undergone a fusion involving the occipito-atlanto-axial region. Case notes were reviewed and a radiological analysis was done. Results: Sixteen patients were managed with onlay fusion and external immobilisation, and 27 patients were managed with internal fixation using screw-rod constructs. The fusion rates were 80% and 90.5% respectively. Allograft bone grafting was found to be a significant risk factor for non-union. Conclusion: The screws can be safely and predictably placed as confirmed on radiological follow-up with a high fusion rate and an acceptable complication rate. Uninstrumented onlay fusion with halo immobilisation remains an acceptable alternative. Allograft in the form of bone croutons or demineralised bone matrix is a significant risk factor for non-union, and posterior iliac crest graft should be used preferentially. Level of evidence: Level 4

'Out with the old and in with the new' - a retrospective review of paediatric craniocervical junction fixation: indications, techniques and outcomes