Fixed Cervical Kyphosis and Recurrent Myelopathy

History

The patient is a 69-year-old male. He is a retired college professor.

In 2008, he was diagnosed with cervical spondylotic myelopathy, and in 2009, he had a PCDF. The patient had progressive neck pain and weakness for 2 years post-surgery, and BUE+BLE spasticity, which led to recurrent myelopathy.

He experiences severe neck pain/weakness, and there is a loss of horizontal gaze.

Examination

On examination, the patient had loss of horizontal gaze. He also had neck pain and weakness.

Prior Treatment

The patient previously had a C2-C5 PCDF.

Pre-treatment Images

Figures 1A and 1B: AP x-ray (left) and lateral x-ray (right) showing C5-C6 adjacent segment instability and sagittal C1 plumb line.Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figures 2A and 2B: Flexion x-ray (left) showing junction instability and extension x-ray (right) showing fixed kyphosis. Note that there is no gross C1-C2 instability. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figure 3A: Sagittal MRI showing pannus and fixed C1 arch compression. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figure 3B: Axial MRI showing C1 posterior arch with cord signal change. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figures 4A, 4B, and 4C: Axial MRIs showing C5-C6 (left), C6-C7 (middle), and C7-T1 (right). Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Diagnosis

The patient was diagnosed with fixed C2-C5 kyphosis and recurrent myelopathy (C1 posterior arch compression). There is also adjacent segment instability at C5-C6.

Selected Treatment

After exposing and exploring the occiput to T2 posteriorly, a solid C2-C5 fusion was identified. Hardware was removed from C2-C5, and then fusion mass osteotomy of C4-C5 bilaterally using an outside-in technique was done. The patient also had a complete bilateral laminoforaminotomy at C5-C6, occiput to T2 instrumentation, and C1 posterior laminectomy.

For the second stage of the surgery—the anterior stage—a left-sided transverse incision (4.5 cm) was made. First, ACDFs were performed at T1-T2, C7-T1, and C3-C4 (using fibula allograft and local autograft). Then, anterior C6-C7 and C4-C5 osteotomies were performed, followed by ACDF at C5-C6.

For the third part of the surgery—another posterior approach—reduction was performed (Mayfield extension), along with fusion from C2-T2 and rod placement.

Intraoperative Image

Figure 5: Intraop lateral x-rays during second posterior stage. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Post-treatment Images

Figure 6: Post-operative photo showing anterior incision. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figure 7. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Figures 8A and 8B: Lateral x-ray and clinical photo of patient after surgery. Image courtesy of Todd J. Albert, MD, and SpineUniverse.com.

Outcome

The patient was intubated for 24 hours following surgery to protect the airway.

He was discharged 5 days following surgery, and the plan at that point was to wait 8 to 12 weeks before returning the patient to the OR for removal of the occipital plate and rods above C2. A CT scan would be done prior to that in order to evaluate the C2-T2 fusion.

Case Discussion

Tyler Koski, MD

Assistant Professor, Neurological Surgery

Northwestern University, Feinberg School of Medicine

This patient is a 69-year-old retired college professor with symptoms of cervical myelopathy with prior fusion. His imaging findings show both kyphosis and signs of degeneration above and below his construct.

Of note, his kyphosis appears to be relatively fixed as there is little correction of the kyphosis from his upright x-rays to his supine MRI. The other pertinent finding is that he appears to have C1-C2 degeneration with anterior pannus formation.

The pannus combined with the multi-level degenerative changes does raise the question of rheumatoid arthritis, and it is unclear from the history that it was present or a part of the workup.

His clinical history and his imaging findings seem to match well and that he does have spinal stenosis. That would explain his current myelopathy, and the kyphosis may certainly relate to his progressive neck pain.

Treatment options include all of those listed by the authors. The decision to do single-stage vs multi-stage operations often times has to do with whether the deformity is truly fused in its current position.

In this case, my standard workup would include a CT scan to access the facet joints to evaluate if they are fused or mobile. If the facets appear to have some mobility, I would likely perform a single-stage anterior then posterior operation with anterior releases and multi-level interbody grafting to partially restore lordosis and complement this with posterior facet osteotomies and final correction of deformity.

In the setting of ankylosing facet joints, I tend to opt for a procedure similar to that described by the author. This would include a stage 1 posterior instrumentation removal and facet releases followed by 48 hours of halo traction and then a second stage anterior posterior reconstruction.

Selection of fusion levels is likely controversial in this setting with the C1-C2 pannus being of some clinical concern, particularly because that is the level of the presumed stenosis that is causing his myleopathy. Instrumentation extending up to C1 or the occiput as was done in this case is often times necessary, and with immobilization of the C1-C2 segment one can see resolution of the pannus.

Interestingly, in this case, the author elected to include the occiput initially and then remove the instrumentation for a final fusion of C2-T2. This technique may be beneficial from a motion preservation standpoint but runs the risk of the C1-C2 pannus increasing and potentially becoming problematic again in the future.