Sir,
A 69-year-old female with significant past medical history of polio and neuromuscular
scoliosis status post noninstrumented thoracolumbar fusion presented with gradually
progressive severe cervical spinal kyphosis to the extent that she had difficulty
maintaining upright gaze. She had subtle signs of myelopathy but was otherwise neurologically
intact. Imaging with upright cervical spine X-rays, magnetic resonance imaging (MRI)
and computed tomography demonstrated fixed cervical kyphotic deformity with the presence
of ankyloses both anteriorly and posteriorly [[Figure 1]]. She underwent surgery through a single stage 360° approach with anterior osteotomy
and release with the placement of standalone intervertebral polyetheretherketone cages
with integrated fixation followed by posterior release and instrumented fusion [[Figure 2]]. The standalone device was secured with only a single screw after anterior osteotomy
to allow further lordosing the spine after posterior release of the fused facet joints.
An excellent restoration of cervical spine alignment with correction of deformity
was achieved [[Figure 2]].
Figure 1: Upright lateral cervical spine X-ray (a) sagittal computed tomography (b and c) and
sagittal T2-weighted magnetic resonance imaging (d) demonstrating fixed cervical kyphotic
deformity with presence of ankyloses both anteriorly and posteriorly. (arrows in image
b and c) and cervical spinal cord compression (d) There is presence of 32° of cervical
kyphosis between C2-C7 and about 8 cm C2-C7 sagittal vertical axis
Figure 2: Lateral X-ray (a) and sagittal computed tomography (b) of the cervical spine showing
restoration of cervical lordosis and C2-C7 sagittal vertical axis
Adult spinal deformity has become an increasingly common pathology encountered and
treated by spine surgeons secondary to the increasing life expectancy and expectations
of elderly patients to remain functional so as to maintain a reasonably active lifestyle
and quality of life (QOL). There has been an outburst of advancement in the management
of thoracolumbar adult spinal deformity in the past decade or so. In contrast to thoracolumbar
deformities, considerably less progress has been made in the study of adult cervical
deformity. Recent studies have shown that symptomatic cervical deformity impacts QOL
to a degree comparable to or more than a number of chronic diseases.[[1]] The most common forms result from degenerative spondylotic and inflammatory arthropathies
or iatrogenic conditions and can produce “chin-on-chest” deformities that can substantially
impact fundamental functions, including horizontal gaze, swallowing, and breathing
often necessitating surgical treatment. The surgery for adult cervical spine deformity
remains challenging with no major advances involving the principles of corrective
surgery. A number of the algorithm have been proposed in the past with the main distinction
being between flexible and rigid deformity leading to the selection of either anterior
alone, posterior alone, combined anteroposterior or posterior-anterior-posterior approach
based mainly on the presence or absence of ankyloses and its location.[[2]] It has been fairly agreed on that a fixed deformity with a posterior ankylosis
needs a posterior release first thus requiring a 540° approach with posterior osteotomy
followed by anterior release with interbody grafting followed by posterior instrumentation
and fusion thus requiring two flips during surgery and increased overall operative
time with its associated morbidity and remains the most common approach for treated
cervical deformity with posterior ankylosis.[[2]] Kim et al. have popularized and have described in great detail the anterior osteotomy
techniques to allow correction of complex cervical fixed deformity that when appropriately
combined with posterior release can be utilized to treat fixed cervical deformity
with even posterior ankylosis through a 360° approach.[[3]] This cases have been reported mainly from the same author questioning the wider
applicability of the technique. This case illustrates a patient with severe cervical
deformity with the presence of ankyloses both anteriorly and posteriorly treated via
a standard 360° approach. While the details of the surgery can be read elsewhere,[[3]] the key intraoperative steps involved anterior osteotomy followed by placement
of wider interbody cage or graft with a smaller height and univertebral fixation followed
by posterior release and instrumented fusion. Implants with slightly less height and
univertebral fixation help maintain slight flexibility in the spine thus allowing
further lordosis after the posterior release. The importance of utilizing open Jackson
table with head supported in the Gardner wells tongs with bivectral traction cannot
be overemphasized.
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