Fusion Nonunion with Progressive Kyphosis
A 58-year-old female presents to the outpatient clinic with a chief complaint of severe neck pain and difficulty holding her head up. Two years ago she underwent posterior cervical laminectomy and fusion for cervical spondylotic myeloradiculopathy by another surgeon. Post-operatively her radicular symptoms, balance disturbance, and fine motor difficulties all resolved, but she had no relief of her neck pain. Over the course of the following two years her neck pain progressively worsened and became debilitating. She had progressive difficulty and fatigue when trying to maintain horizontal gaze. She is now unable to work due to her pain.
- 5' 5", 130 lbs, well-appearing
- Posterior neck musculature splayed laterally, hardware easily palpable
- Neck tilted forward, limited cervical ROM, but able to hold up head for horizontal gaze
- 4/5 triceps strength bilaterally, otherwise neurologically normal
- Symmetric DTRs, negative Hoffman, no clonus
- Normal gait
- Physical therapy for 2-3 months
- Trigger point injections
- Epidural injections
- Facet blocks
Figure 1. Lateral x-ray of the cervical spine showed previous C3-T1 laminectomy and fusion. There is a nonunion at C3-C4 with near-complete dislodgement of C3 screws, and kyphosis of the C2-C3 and C3-C4 levels.
Nonunion of cervical fusion with progressive kyphosis
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Posterior osteotomy, anterior reconstruction, revision posterior fusion (back-front-back).
Stage 1: posterior removal of hardware, Smith-Peterson osteotomies at C3-C4 and C4-C5. Intra-operative imaging during this part of the procedure shows the lateral fusion mass, after the hardware has been removed. Smith-Peterson type osteotomies were performed at C3-C4 and C4-C5. Screw holes at C3 and C4 were seen to be irregularly shaped and eroded, consistent with pre-operative toggling of the instrumentation. (Figure 5)
Figure 5. Intra-operative photo of first part of procedure. Here the hardware is removed and the lateral fusion mass is shown.
Stage 2: anterior reconstruction with ACDF from C2-C5 with instrumentation and iliac crest allograft. Intra-operative x-ray following the second stage showed anterior cervical discectomies with placement of iliac crest allograft at C2-C3, C3-C4, and C5. The kyphosis has been corrected (Figure 6).
Stage 3: revision posterior fusion C2-T1 with iliac crest autograft Intra-operative x-ray following the third stage showed placement of posterior instrumentation from C2-T1, and bone grafting with iliac crest autograft (Figure 7).
Figure 7. Final intra-operative x-ray after third stage.
In the immediate post-operative period, the patient was extremely satisfied with her overall appearance. She developed significant dysphagia following surgery and was evaluated with a swallow study that showed aspiration. A naso-duodenal tube was placed for enteral feedings and removed 6 weeks post-operatively. Her swallowing function has since returned to normal. She remained neurologically intact and otherwise had an uneventful post-operative course.
A post-operative lateral cervical spine x-ray taken 6 weeks later showed maintenance of the correction (Figure 8).
Figure 8. Post-operative lateral x-ray at 6 weeks.
As we advance our science and technical skill in the cervical spine, I suspect we will begin to see these adjacent level problems more frequently. This case was expertly managed by Dr. Gordon and Dr. Kang. The "dropped head syndrome," or "chin-on-chest deformity" is becoming more commonplace, particularly at larger referral centers. They can present with neurological symptoms but surprisingly can come in with the straightforward complaint of difficulty with horizontal gaze.
The goals of these surgeries are: 1) restoration of gaze, and 2) solid arthrodesis.
The authors accomplished these goals with a staged procedure. Good lordosis was achieved, thereby restoring the patient's gaze. And, because of the anterior-posterior construct, they achieved solid arthrodesis without including the occiput. Deformity correction through ACDF is often very successful, and because of their work posteriorly they could adequately achieve good lordosis. I am sure that not including the occiput was a difficult decision, due to difficulty of achieving arthrodesis when including the occiput. Additionally, the significant morbidity of occipital-cervical fusion should be taken into strong consideration when performing upper cervical spine fusions.
The artistry of this case lies on the fact that these surgeons did just the right amount of surgery necessary to achieve their goals and restore this unfortunate woman's quality of life.