Post-laminectomy Cervical Kyphosis

History

The patient is a 58-year-old male who presented complaining of severe neck pain. He had mild bilateral arm pain too.

Examination

The patient is neurologically intact.

Prior Treatment

Previously, the patient had a C3-C6 laminectomy.

To address his current pain, he has tried conservative therapy, but he has not found relief.

Images

Figures 1, 2, and 3 demonstrate significant post-laminectomy kyphosis.

Figure 1: Lateral radiograph in neutral position. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 2: Lateral radiograph in flexed position. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 3: Lateral radiograph in extended position. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 4: Sagittal MRI demonstrating cervical kyphosis with spinal cord compression at C3.Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Diagnosis

Post-laminectomy kyphosis with spinal cord compression at C2-C3.

Selected Treatment

The patient had a 2-stage surgery. The first procedure was an anterior multi-level discectomy to correct the deformity. This was achieved by segmental distraction at four different disc space levels. The patient's head and neck were also repositioned on the operating room table following the discectomies. Trapezoidal-shaped bone grafts were placed into each disc space to help maintain the correction. Anterior fixation was inserted from C3-C7.

The anterior approach was selected as the initial procedure because the pre-operative images demonstrated the posterior facet joints to be mobile. If the facets were found to be ankylosed and non-mobile, an initial posterior approach to perform facet osteotomies would have been preferable.

Following completion of the anterior portion of the procedure, the patient underwent a posterior fixation and fusion procedure from C2 to T1 in order to re-establish his posterior tension band and to provide further support to the deformity correction. The inferior margin of the C2 lamina was removed because of persistent epidural compression at that level.

Intra-operative lateral radiograph (Fig. 5) prior to multi-level discectomies and distraction. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 6. Intra-operative lateral radiograph following multi-level discectomies and distraction. This demonstrates significant correction of kyphosis.Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Outcome

Immediate post-operative lateral radiograph (Fig. 7) demonstrating C3-C7 anterior fixation and fusion and posterior C2-T1 fixation and fusion.

Figure 7. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 8: Immediate post-operative AP radiograph. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

The patient reported significant pain improvement following surgery.  He continues to do well 4 years postoperatively.

Case Discussion

Gerard J. Girasole, MD

Orthopaedic Surgeon

Connecticut Orthopaedics

This case demonstrates significant kyphosis and should be addressed primarily anteriorly, with multiple discectomies and fusion (or, if needed, corpectomy), combined with plating C3-C7. I would do posterior fixation / fusion. However, I would not go to C2 as there is no motion on flexion at C2-C3, and thus I do not feel it necessary to stabilize this level. I would prefer to maintain the patient's motion at this level.