Neck Pain and Kyphotic Deformity Post-dental Procedure
A 38-year-old female with no significant medical history began experiencing neck pain shortly after a dental procedure. Because she was already taking a narcotic for chronic back pain, she presented to her pain medicine physician who increased the dose.
The neck pain increased, and she developed a fever. Again, the pain medicine physician increased the dose of her pain medication. It is not clear if the pain physician treated the fever or knew about it. The patient’s pain physician’s practice was shut down by the Drug Enforcement Administration (DEA), and the patient presented to a different physician about her increasing neck pain.
The patient quickly developed a kyphotic deformity. Her insurance status presented further difficulties, and she eventually was referred to our office after approximately 10 months of pain and 8 months of deformity. During those times, although she never received antibiotics, she appeared to have cleared the infection.
The examination shows her head position to be consistent with pretreatment imaging and is fixed. The patient considers this to be intolerable.
- Her left non-dominant arm shows mild hyperreflexia; 4/5 strength. The patient thinks the dysfunction is increasing.
- Her exam is otherwise benign.
- She has no chronic medical problems, and is a non-smoker.
ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) were within normal limits at the time of presentation.
- Plain film (Fig. 1)
- MRI (not shown) shows cord draped over kyphus. Otherwise, no stenosis.
- CT scans (Figs. 2, 3)
- 3D reconstruction CT (Fig. 4) shows 90-degrees of fixed deformity, including solidly fused C5-C6 disc space and posterior elements
Fixed kyphotic deformity
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Option 5 was chosen: Posterior resection, anterior resection/reconstruction and posterior fusion (P-A-P).
With no medical concerns, no osteoporosis, and no previous surgery, all options were on the table. I considered preoperative halo traction, but she had skipped two preop appointments, had young kids at home, and was not likely to agree to it. With solid fusion—both anteriorly and posteriorly—each had to be resected prior to any meaningful correction. While partial correction was a possibility, full correction was entirely plausible and her clear wish.
Figure 5 shows pre-incisional traction with Mayfield tongs. A rigid endotracheal tube needed to be used as a traditional tube kinked due to her severe airway anatomy.
Posterior approach, including resection of the lamina and facets from C4-C5 to C6-C7, with lateral mass screws placed at C3 and C5. Pedicle screws were placed at C7 and T1. C2 screws were left for the third stage because the angle was poor.
Anterior approach, C5 and C6 corpectomy and gradual distraction, including strut graft placement.
Re-opening of the posterior incision, placement of C2 screws, and locking down the rods with full correction. Navigation was not used for screw placement; however, an intra-operative CT scan with the O-arm confirmed appropriate placement of all hardware at closure, and is shown in Figure 7.
The patient was kept in the ICU intubated for 48 hours for potential airway swelling concerns. She was discharged on postoperative day 5, with a normal neurological exam and anatomic head position in a hard collar.
Figure 8 is the patient's 6 month postoperative film.
Her one year follow up exam showed maintenance of her correction and excellent pain relief.
Dr. Kraemer and his group are commended for the excellent care and treatment of this patient's particularly difficult spinal deformity. The case brings attention to the many principles spine surgeons struggle with on a daily basis. As such I would like to review the patient's overall presentation and treatment options.
Any individual, who has a chronic history of opioid use and then develops a change in their pain patterns, should initiate a further workup when appropriate. This patient appears to have developed a cervical discitis, osteomyelitis and was self-medicating herself due to the pain. It does not appear that she was extremely compliant with medical follow-up and evaluations, in that it was approximately one year time after these initial symptoms that she was seen by Dr. Kraemer and his team. In addition to the pain, she developed a chin-on-chest deformity over 90-degrees.
The kyphosis developed despite an autofusion of the previous discitis. It is interesting that a subgroup of healthy patients can overcome the acute infectious discitis and osteomyelitis as is most likely the case in this patient. The resolution of the infection is based on the imaging studies showing no acute infection in addition to normal ESR and CRP laboratory values.
In addition to a well outlined history, examination, and laboratory values, Dr. Kraemer and his team did an excellent job in their pre-operative imaging evaluation. The patient's plain films illustrate the approximately 90-degree focal kyphosis. Although these films were not shown, flexion and extension films were most likely obtained. These dynamic films are extremely important in that they provide an understanding of the flexibility and ability to reduce a deformity. In patients with a flexible deformity one option that is not used as commonly today as previously is cranial traction techniques.This can be helpful in post infectious deformities such to slowly reduce the deformity and maximize realignment.
The difficulty pointed out on this particular patient is illustrated on her cervical spine CT scan. She has a fixed kyphotic cervical deformity confirmed by the fusion of her anterior and posterior spinal elements. Thus, in order to make the spine flexible both the anterior and posterior releases are necessary. Typically, the posterior release is performed first such that an anterior graft and correction of the ventral compression can be done with the second-stage release. Finally, the posterior instrumented fusion can be performed to "lock in" the corrected alignment.
It is important to determine, as Dr. Kraemer and his team did in this case, the flexibility of the deformity such that the optimal surgical approach can be determined. In summary, Dr. Kraemer and his team are commended for their excellent treatment of this difficult deformity and outcome for this patient.