Kyphosis Nonunion with Cervical Spinal Myelopathy
The patient is a 75-year-old male, who is status post laminectomy and fusion at C2-C5. His worsening pain and other symptoms have led to his inability to ambulate.
Treatment included irrigation and debridement (ID) of a questionable wound infection and removal of C2 screws.
He lost his ability to ambulate independently with 3+/5 strength in his lower extremities. Upper extremities showed 4+/5 strength to muscles intrinsic of the hand. The patient's grasp was 4-/5. He has hyper-reflexia in the lower extremities with crossed and inverted radial reflexes and bilateral positive Hoffman's reflexes.
C2-C5 laminectomy and fusion, ID, removal of C2 screws
At presentation, radiographs (Figs. 1A, 1B), CT scans (Fig. 2) and MRI (Fig. 3) were obtained.
Figure 1A. Lateral x-ray
Figure 1B. Anterior posterior x-ray
Figure 2. Sagittal reconstruction of the CT scan demonstrates kyphosis
Figure 3. Sagittal MRI defines tenting of the spinal cord over the kyphosis
Postoperative / post-infectious kyphosis
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The patient underwent instrumentation removal, irrigation and debridement, and culture, followed by intravenous antibiotics for three weeks. Then, posterior implantation of anchors and osteotomies were performed at C4-C5 and C5-C6 (Figs. 4A, 4B).
On the same day, the above procedures were followed by C3-C7 intradiscal segmental correction via anterior cervical discectomy and fusion and occiput to T1 posterior arthrodesis and instrumentation (Figures 5A, 5B).
Figure 5A. Postoperative lateral x-ray
Figure 5B. Postoperative posterior anterior x-ray
Ten days after surgery, the patient developed some increased dysphagia. Radiographs (Fig. 6) and CT scans revealed displacement of the C3-C4 graft (Fig. 7). An anterior revision was carried out with plating (Fig. 8).
At one-year follow-up, the patient progressed to independent ambulation and his upper tract signs have resolved.
This patient was masterfully managed. Iatrogenic cervical kyphosis, particularly those cases that are complicated by infection, present significant diagnostic and treatment challenges. This case illustrates several fundamental, yet critical, aspects of treatment.
One must first treat the infection. In complex or refractory cases, implant removal (particularly, if the implant system is to be replaced) is critical.
Second, deformity correction most commonly requires a staged approach. Such allows for sequential operations, performed at a single or multiple settings that provide a logical and well-conceived approach to deformity correction and maintenance of the correction.
Some surgeons design operative strategies via a multiple setting approach. If the entire correction can be obtained at a single setting, as was achieved here, such should be considered. One must weigh the risks of inadequate deformity correction, duration of overall operative time at a single setting, and medical risk when considering multiple versus single setting surgery. Obviously, if adequate deformity correction cannot be obtained, or the surgeon is not certain of such (usually because of insufficient intraoperative imaging), a second stage may be deemed appropriate.
Third, dorsal osteotomies (wide and complete foraminotomies that are completed by totally disrupting facet joint integrity from medial to lateral via bone removal over the exiting nerve root) are often a necessary component of cervical deformity correction strategy. Without such a releasing procedure, adequate attainment of normal or near normal, alignment may not be achievable. This technique is relatively straightforward yet, foreign to many surgeons. Aggressive deformity correction procedures, such as presented here, should be undertaken by surgeons accomplished in the management of the multiple facets of the operation, including the ability to perform cervical osteotomies.
Finally, dislodgement of ventral grafts, following further correction of deformity, is not unexpected. The patient and family should be counseled regarding the possibility of such an occurrence. Obviously, one should ensure that any dislodgement that, potentially may occur, occurs in a ventral, not dorsal direction. The latter could have catastrophic spinal cord injury implications.
One final caveatthe placement of a ventral plate at the time of the ventral procedure is often not appropriate. Further deformity correction during the final dorsal stage of the overall procedure would be limited by such. Therefore, one must accept the risk of graft dislodgement in such cases. This a small price to pay for a good final outcome in any case as complex as the one presented here.