Surgical management of cervical deformity with osteotomy

Abstract

Cervical sagittal balance is as an important clinical and radiographic parameter. The normal cervical spine is lordodic, and all kyphotic deformities should be explored. In patients with suspected cervical pathology, a thorough history and physical exam is mandatory. While axial neck pain commonly exists with kyphotic deformity, radiculopathy or myelopathy often exists as well. AP and lateral radiographs detect bony abnormalities and disc space collapse. A C2–7 plumb line may be drawn to measure angulation of the cervical spine. Adjuvant CT scan, to further delineate the bony architecture, and MRI scan, to assess for neural compression, are often useful in the management of a kyphotic spine. Nonoperative management is the usual initial mode of treatment. Physical therapy, aimed at posterior cervical paraspinal muscle strengthening, may improve lordosis in patients with flexible kyphosis. Anti-inflammatory medications and injections may cause symptomatic improvement but they do not address anatomic problems. Close follow-up is needed with these patients to monitor for neurologic deterioration. Operative treatment is indicated when nonoperative management has failed or in the setting of severe or rapidly progressive neurologic symptoms. Techniques for sagittal correction exist on a spectrum. Partial facet resections or Ponte osteotomies cause relatively small segmental lordosis but result in large sagittal improvement when used in long constructs. Anterior corpectomy with adjuvant posterior soft tissue release results in more focal lordosis. Three-column osteotomies are performed at either C7 or T1 to avoid the vertebral artery. Anterior column lengthening is relatively more powerful than a pedicle subtraction osteotomy. However, anterior lengthening is associated with a higher risk of damage to the surrounding neurovascular structures and soft tissue due to traction. Lastly, a vertebral column resection results in the greatest angular correction but is rarely performed due to its high potential for complication.