4:04 Circumferential reconstruction of the cervical spine

Abstract Purpose of study: A significant number of adults have pain, cosmetic deformity or neurologic injury related to cervical malalignment. The majority of such cases involve sagittal plane malalignment with loss of lordosis, kyphosis or double curve (swan-neck) deformity of the subaxial spine. A smaller number of patients have coronal plane malalignment or scoliosis in the subaxial spine or various anomalies of the occipitoatlantoaxial complex. In the following, we describe 50 cases within the past 5 years in which circumferential approaches have been applied for the correction of cervical deformities. Methods used: At our institution, more than 50 cases of multisegmental cervical or occipitocervical deformity corrections have been performed since 1995. Thirty cases have at least 24 months of follow-up. Causative pathologies include rheumatoid arthritis, congenital dysplasias, late posttraumatic deformity, iatrogenic postsurgical deformity, severe degenerative disease, tumors, vascular malformations and infections. All subaxial cases involved sagittal plane restoration. One in four also required coronal or axial realignment. Two thirds of occipitoatlantoaxial cases involved sagittal corrections; half with axial or coronal restoration as well. Two thirds of all cases, including 540 degree reconstructions, could be completed in a single day with a single anesthetic. of findings: An aggressive approach to anterior and posterior osteotomy followed by anterior distraction and posterior compression allowed correction of kyphotic deformity in all subaxial cases. Partial loss of correction occurred in one third of cases secondary to cage or strut settling or telescoping, despite rigid fixation. Intraoperative correction of coronal or axial deformities was maintained with little, if any, subsequent loss. Rigid screw fixation to the suboccipital keel and to the C1–C2 region with long C2 pars screws or C1–C2 transarticular screws allowed maintenance of intraoperative correction with no apparent late loss. There were no deaths and no spinal cord or nerve root injuries in this series. Two vertebral artery injuries related to C1–C2 transarticular screw placement occurred; one resulted in a delayed Wallenburg's syndrome. Two next-segment failures occurred, requiring reoperation for extension of fusion. There was a measurable loss of anterior distractive height restoration in one third of cases over time. In no case was this clinically significant. Anterior cage or strut settling occurred with both rigid and dynamic anterior buttresses and in the face of rigid anterior and posterior hardware. Relationship between findings and existing knowledge: The literature on spinal deformity is largely concerned with thoracic and thoracolumbar pathology. Traditional surgical approaches to cervical deformity using nonrigid internal fixation with wire or cable and/or semirigid external fixation in halo vests or Minerva casts were of limited use in the correction of deformity in any plane either above or below C2. Overall significance of findings: Modern reconstructive techniques allow for clinically significant correction of cervical and occipitocervical deformities associated with chronic pain, cosmetic deformity and neurologic deficit. An aggressive circumferential approach to decompression and osteotomy allows near-anatomic correction of geometric deformity in any plane. Disclosures: No disclosures. Conflict of interest: No conflicts.