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Adopting 540-degree fusion to correct cervical kyphosis
Spine
Adopting 540-Degree Fusion to Correct Cervical Kyphosis Anthony H. Sin, M.D., Rajesh Acharya, M.D., Donald R. Smith, M.D., and Anil Nanda, M.D., FACS Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, Louisiana Sin AH, Acharya R, Smith DR, Nanda A. Adopting 540-degree fusion to correct cervical kyphosis. Surg Neurol 2004;61:515–22. BACKGROUND
Two cases of severe cervical spine kyphotic deformity resulting from late effects of infection were successfully corrected by combined anterior and posterior instrumentations in a single operative sitting. CASE DESCRIPTION
Case 1 is a 43-year-old man who developed severe cervical kyphosis from C5-6 discitis over a few months despite long-term antibiotic therapy. He was neurologically intact except for severe neck pain and obvious deformity. Case 2 is a 40-year-old woman who had a previous wound infection five years before presentation. There was gradual worsening of swan neck deformity at the C2-3 and C5-6 levels with some spinal cord compression worsening her baseline myelopathy. The patients were placed and maintained in cervical traction on the Stryker frame for the duration of the procedure. Both cases required anterior approach initially to achieve some release of dense scar tissue using a high-speed drill. The wounds were then closed and patients were rotated to the prone position for further release of fused bony elements, including the facets. Lateral mass screws and plates were placed. In Case 2, additional instrument to the occipital was performed to stabilize the C2 using a U-shaped cervical rod. Once adequate reduction had been achieved, the patients were rotated back to supine position for further corpectomy and fibular construct fusion with plates. CONCLUSION
In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches. © 2004 Elsevier Inc. All rights reserved. KEY WORDS
Cervical spine, kyphosis, operative approach osteomyelitis, spine fusion.
Address reprint requests to: Anil Nanda, M.D., FACS, Professor and Chairman, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130 –3932. Received March 12, 2003; accepted June 2, 2003. © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
pinal osteomyelitis is uncommon, constituting 1% of all bony infections. The cervical spine is affected in only 3 to 6% of these, thus rendering it a clinically rare entity [8,10]. The vertebral body, which may be a primary site or involved secondary to invasion from the adjacent disk space, is involved in only about 8 to 16% of all pyogenic bone infections [2]. The initial clinical manifestation is non-specific, thereby delaying the diagnosis and often leading to vertebral body collapse, kyphosis, and neurologic deterioration. The management of severe kyphotic deformity is challenging, and the literature on this subject is scarce. We present two cases with severe kyphotic deformity complicating cervical osteomyelitis, which were managed successfully with 540-degree fusion with instrumentation.
S
Case Material CASE 1 A 43-year-old male presented with severe neck pain and progressive neck deformity of 3 months duration. There was no history of previous cervical problems or surgery. He had a significant history of IV heroin abuse. His neck pain worsened three months before presentation. The work-up done by his primary physician was consistent with C5-6 discitis and a long-term IV antibiotic therapy was initiated. Blood cultures grew Pseudomonas organisms although cultures taken from direct puncture site were negative. He continued to manifest neck pain and deformity despite medical therapy. The patient was referred to our institution for possible surgical intervention to correct the deformity. He denied any radiculopathy, numbness, weakness, gait difficulties, or bowel/bladder dysfunctions. Past medical history was negative for any heart disease, diabetes, cervical spine trauma, chronic steroid use, and hypertension. He had admitted to smoking 1.5 0090-3019/04/$–see front matter doi:10.1016/S0090-3019(03)00542-1
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Plain lateral view cervical X-rays in (A) flexion and (B) extension demonstrating severe destruction of C5-6 vertebra and almost 90-degree kyphosis at C5-6 level (Case 1).
packs of cigarettes per day and regularly consuming alcoholic beverages. Extension of the cervical spine was quite limited to the point that any gaze above the horizontal plane was possible only with marked over extension of the trunk. Examination of the motor and sensory system along with the gait was normal. Plain X-ray of the cervical spine, in flexion (Figure 1A) and in extension (Figures 1B), showed severe destruction of C5 and C6 vertebral bodies along with almost 90-degree kyphosis. Magnetic resonance imaging (MRI) of the cervical spine did not demonstrate any spinal cord involvement (Figures 2A, B), which was consistent with absence of neurologic deficit despite the marked deformity. The recommendation was made to surgically correct his cervical deformity. DESCRIPTION OF OPERATION The procedure comprised of three separate operative procedures carried out during a single session in the surgical suite. A Stryker frame allows for the constant application of skeletal traction during the repositioning of the patient in supine-prone-supine positions for
anterior-posterior-anterior surgical corrections. This repositioning sequence is called the 540-degree approach. Following general endotracheal anesthesia, Gardener-Wells tongs were applied to provide traction throughout the entire operative procedure. Because of the extreme degree of kyphosis, the patient’s head and chin were deformed in anterior flexion even with the traction. An oblique incision was made just anterior to the sternocleidomastoid muscle. We then performed a dissection from the anterior cervical region medial to the carotid sheath and its contents. Exposure was quite difficult because of the marked flexion deformity. The vertebral bodies at C5 and C6 were not visible anteriorly as the anterior inferior margin of C4 abutted the anterior superior surface of C7 (Figure 1A). We found thickened scar and fibrotic mass material in the region, but no obvious purulent material was found. A partial transverse resection of the longus colli muscles as well as removal of calcified scar tissues and residual bone with a high-speed drill allowed some relaxation of the deformity and straightening of the cervical spine. The posterior longitudinal
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Preoperative T2-weighted MRI images (A) sagittal and (B) axial views demonstrating severe kyphotic deformity without spinal cord compression (Case 1).
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(A) Postoperative plain X-rays showing good resolution of kyphosis with adequate placement of instrumentations and (B) alternate view (Case 1).
ligament was identified after further resection of portions of the C5 and C6 bodies as widely as possible under direct visualization with the operating microscope. The majority of deformity persisted because of posterior element fixation. The anterior wound was packed and closed to proceed unto the second procedure from the posterior approach. After rotating the patient in a prone position, skin incision from inion to C7 spine was made. The muscular and ligamentous attachments were separated and C5-6 spinous processes were identified. The facets at C4-5 and C5-6 were fused and immobile. The lamina, posterior facets, and lateral masses of C5 were radically removed with the high-speed drill to free these fusions. After the lateral bony masses of C5 had been removed, there was a greater visible reduction of curvature. When this reduction was complete, there was approximation of the spinous processes of C4 and C6. The lateral mass screws were placed at the levels of C4, C6, and C7 using C-arm fluoroscopy (Figure 3A). The posterior rods were then fitted to the desired contour and secured to the bone with lateral mass screws allowing further reduction to the cervical curvature. Additional
morcellized bone fragments from the spinous processes and bone dust salvaged from the corpectomy were then packed laterally at the site where the facets had been decorticated. The wound was closed in multiple layers after copious irrigations. The last stage was instrumentation anteriorly in the supine position. Upon reopening the anterior wound, there had been a remarkable reduction in the cervical deformity and the corpectomy of C5 and C6 was complete. The inferior surface of C4 and superior surface of C7 were decorticated and a slight recess was placed in each as the receptacle for the bone graft using the high-speed drill. A fibular strut was placed to bridge the defect, and the bone marrow cavity was packed with bone dust from the corpectomy. An anterior plate was selected of an appropriate length to bridge from C4 to C7. This plate was then placed and secured to C4 and C7 with 2 screws each (Figure 3B). Two intermediate screws were placed into the fibular graft through previously drilled holes in the graft and prepared by tapping. Following intraoperative radiographic confirmation, the wound was closed. The patient was monitored throughout this proce-
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Plain X-rays showing severe kyphosis with subluxation at C2-3 levels (Case 2).
dure with evoked potentials and they remained stable during the entire case. At the close of the procedure, the Gardener-Wells skeletal tongs were removed and replaced with a Miami-J hard collar. CASE 2 A 40-year-old female had developed quadriplegia following a motor vehicle accident in 1985. She had previously undergone a posterior laminectomy and fusion at another medical center. She was later referred to us because of worsening symptoms in her right side with worsening spasticity and pain over the last few years and obvious deformity in her cervical spine. The radiographic studies showed swan neck deformity at C2-3 and C4-5 and the fixed deformity at the fused segment (Figure 4). In view of the worsening neurologic status, surgery to alleviate her symptoms and surgically correct the deformity to halt further deterioration was planned (Figure 5). For the C5 burst fracture, she underwent C5 corpectomy with iliac graft fusion. Her postoperative course was complicated by infection at the operative site requiring open drainage of the wound and antibiotics. She improved significantly, but was stable with a residual right upper extremity paresis and spasticity in the lower extremities.
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DESCRIPTION OF OPERATION After oral general endotracheal anesthesia, GardenerWells tongs were applied providing 15 lbs traction throughout the operative procedure. An oblique incision was made immediately anterior to the sternocleidomastoid muscle followed by further dissection down to the anterior cervical region medial to the carotid sheath and its contents. The entire anterior vertebral bodies from C2 to C7 were exposed. The deformities involved upper cervical levels warranting a radical corpectomy of the anterior fused C4, C5, and C6 segments. The removal of the bone continued in the bone graft area until the posterior longitudinal ligament and dura were visible. Using a high-speed drill we laterally cut through the bone until the entire bony segment had been bilaterally sectioned allowing only a slight reduction of the kyphotic deformity. The surgical site was then packed and skin was closed to proceed with the second part of the operation posteriorly. In the prone position, a vertical skin incision from the occipital region to T1 level was made. A solid bony fusion was noted bilaterally incorporating C4, C5, and C6. Marked anterior listhesis of the facet joints were noted at C2-3 and C3-4. Along with extensive laminectomies, multi level facet joint removal was performed with the high-speed drill. The fused bone was divided laterally into separate segments to allow further reduction of the kyphosis with instrumentation. A cervical rod was contoured in a U-shape with a slight lordotic curve. The lateral mass screws were placed bilaterally at C3 and approximately C5 and C7. Once the screws were in place, the rod was connected to the screws. Sublaminar wires were placed underneath the C2 lamina bilaterally and twisted about the superior portion of the rod loop to draw the superior segments of the cervical spine posteriorly and effect some reduction in the kyphotic curve. After all the screws were tightened, a considerable reduction in the kyphotic deformity and essential straightening of the cervical spine was achieved. The incision was closed in multiple layers of cervical muscle fascia, subcutaneous tissue, and skin. The patient was placed back into the supine position for the final stage. The incision was reopened, and retractor was replaced to distraction. A fibular graft was taken and contoured to fit snugly between the inferior portion of C2 to the superior portion of C7. A plate was selected to fit from C2 to C7 level. Two screws were placed each in C2 and C7 bodies and a single screw in the fibular graft. Bone dust from the drill was packed about this graft, and the marrow cavity of the fibular strut had been previ-
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T2 weighted sagittal MRI images demonstrating kyphosis with spinal cord compression (Case 2).
ously filled with this same material. At the completion of the operation, the skeletal tongs were removed and a Philadelphia collar was placed.
Results Case 1 recovered well from the procedure without any neurologic deficits and was discharged 5 days later. At the 60-day, postsurgical follow-up, the patient was pain free without any medication and neurologically intact. The patient’s immediate postop and 60-day X-rays were comparatively unchanged (Figure 3B). Case 2 recovered well from the procedure without any signs of worsening of the neurologic status (Figure 6A). Her strength in both sides was the same as the baseline, but she required some rehabilitation for gait training. She had been unable to ambulate before surgery secondary to her deformity and severe pain. At 12 months follow-up, the spinal alignment and fusion have been satisfactory without the cervical collar (Figure 6B). The patient is ambulating with only a mild gait spasticity.
Discussion Cloward suggested multiple factors leading to disk space infection with or without associated vertebral osteomyelitis. These include iatrogenic infections following: (1) disc operations, (2) discography, and (3) other injections delivered adjacent to the spine (1). Increased incidence of sepsis in hospitalized patients is another factor responsible for some of these cases. Individuals with diabetes mellitus, chronic steroid therapy, renal failure, and systemic infection are believed to be at a higher risk for developing spinal infections [7]. Although the prevalence of spinal infection involving the cervical level is lower than the lumbar or thoracic levels, the risk of developing neurologic deficit with such infections of the cervical area is much higher because of limited spinal canal space compared to other levels [8]. The anterior portion of the vertebral body is involved more frequently than the posterior elements. The scarring and contracture in this area may result in a kyphotic deformity [11]. The leading organism for spinal infection is Staphylococcus aureus. The emergence of IV drug abuse in recent years is another prominent factor leading to many such infections [8,3].
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(A) Immediate and (B) 6 months postoperative plain X-rays showing improved alignment of the spine (Case 2).
The presence of severe neck pain, especially in a febrile patient, should arouse the suspicion of cervical osteomyelitis. This is especially true if of the patient has one of the above mentioned predisposing factors [10]. The majority of spinal infections are treated successfully with IV antibiotics when diagnosed promptly and if the therapy is initiated with appropriate coverage for the organism. Once an infectious etiology is suspected or has been proven with positive blood cultures and/or tissue diagnosis, the usual recommended treatment is 4 – 6 weeks of IV antibiotics concurrently with an external spinal orthotic device. Surgical intervention is warranted in the presence of (1) neurologic deficits secondary to compression from epidural collection or kyphosis; (2) prevertebral collection causing severe pain and pressure; (3) progressive kyphotic deformity [1,10]. The goals of surgery in cervical osteomyelitis may include: decompression of the neural elements, collection of tissue for pathologic analysis and culture, debridement of destroyed vertebral bodies and stabilization by performance of fusion. Most of the cases of cervical osteomyelitis described in the literature have been managed by anterior debridement and fusion [1,10]. Only anec-
dotal cases of combined anterior as well as posterior approaches have been found [1,10]. In these 2 patients reduction of the severe deformity required a combined approach with progressive release of the fused elements both anterior and posterior to allow satisfactory alignment. The combined approach also spares the patient the necessity of having a second or third separate major procedure. Both patients were discharged on fifth postoperative day, which illustrates the reduced duration of hospital stay with the substantial decrease in overall cost of this complex treatment. The first patient had positive blood cultures for Pseudomonas organisms, but the actual tissue culture sent from a needle aspiration had failed to grow any organisms. This is not unexpected after a long duration of antibiotic therapy [3]. This patient’s spinal alignment deteriorated rapidly, despite aggressive medical therapy for several months. Fortunately, he remained devoid of neurologic deficits though the radiographic studies revealed extreme kyphosis. The second patient had an infection more than 10 years before this presentation. Before surgery her baseline neurologic function was declining with progression of the kyphosis.
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The operation relieved much of her pain but also improved her spasticity and strength. These 2 cases illustrate combined anterior and posterior instrumentation to correct severe kyphosis complicating cervical osteomyelitis. Surgical intervention with evacuation and stabilization at an earlier phase of the infection, at the first sign of clinical deterioration or at no response to the medical treatment would have prevented such a high degree of deformity. The infections involved compression of vertebral bodies and fusion of the cervical spine at multiple levels resulting in a debilitating kyphotic position at the time of presentation to our institution. The severe deformities in these patients failed to reduce the kyphosis despite concurrent skeletal traction in initial anterior approach and subsequent corpectomies. Even after anterior release had been accomplished, the kyphosis remained relatively fixed because of associated fusion between the posterior elements of adjacent segments. This fixation required associated release from the posterior approach. Segmentation of the fused segment bilaterally with the high-speed drill was required to attain reasonable reduction of the abnormal curvature. The second case involved a higher cervical level than the first case, and required inclusion of C2 in the instrumentation posteriorly in the form of sublaminar wires. Finally, when both anterior and posterior release had been accomplished, the instrumentation and fixation could be accomplished. After completion of the posterior instrumentation, the patient was rotated back into supine position for a fibular strut and plate anteriorly. Both patients had excellent clinical as well as radiographic results.
Conclusion The occurrence of chronic neck pain in immunocompromised patients, or patients with a recent history of spinal surgery, drug abuse, and diabetes should be viewed as highly suspicious and evaluated for possible infections. In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches. This allows complete release of both anterior and posterior fixation. It also avoids the risk of a second surgery, shortens the duration of hospital stay and reduces the costs incurred. REFERENCES 1. Cloward RB. Metastatic disc infection and osteomyelitis of the cervical spine. Spine 1978;3(3):194 –201.
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2. Garcia A, Granthal SA. Hematogenous pyogenic vertebral osteomyelitis. J Bone Joint Surg 1960;42A:429. 3. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25(13):1668 – 79. 4. Levi AD, Dickman CA, Sonntag VK. Management of postoperative infections after spinal instrumentation. J Neurosurg 1997;86(6):975–80. 5. Liebergall M, Chaimsky G, Lowe J, Robin GC, Floman Y. Pyogenic vertebral osteomyelitis with paralysis. Prognosis and treatment. Clin Orthop 1991;269:142– 50. 6. Malik GH, Crawford AH, Halter R. Swan-neck deformity to osteomyelitis of the posterior elements of the cervical spine. J Neurosurg 1979;50:388 –90. 7. Messer HD, Litvinoff J. Pyogenic cervical osteomyelitis. Arch Neurol 1976;33:571–6. 8. Schimmer RC, Jeanneret C, Nunley Jeanneret B. Osteomyelitis of the cervical spine. J Spinal Disord Tech 2002;15(2):110 –7. 9. Stone DB, Bonfiglio N. Pyogenic vertebral osteomyelitis. Arch Intern Med 1963;112:491–500. 10. Stone JL, Cybulski GR, Rodriguez J, Gryfinski ME, Kant R. Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine. J Neurosurg 1989;70:879 –83. 11. Wiley AM, Trueta J. The vascular anatomy of the spine and its relationship to pyogenic vertebral osteomyelitis. J Bone Joint Surg 1959;41B:796 –809.
COMMENTARY
The authors have provided a valuable service in presenting 2 very interesting cases of cervical kyphosis managed through a front/back/front approach (540-degree fusion). Clearly such an aggressive process is necessary for the correction of severe cervical kyphosis, as is shown. The question, however, is whether correction of deformity is essential. Certainly, the pain would likely be improved if the deformity is reduced from the 40- to 50-degrees minimum evident to a much more physiological alignment. Secondly, the distortion of the spinal cord will be further reduced. One caution: we generally recommend fixation being performed at least one level above the deformity. Thus, in the first case, we probably would have placed the posterior screws at least into C3. In the second case, with wire going into C2, it would have been tempting to take fixation up higher to improve healing. However, despite these possible technical issues, the procedure described by the authors should be in the armamentarium of those managing complex cervical deformities. Dennis J. Maiman, M.D., Ph.D. Spinal Cord Injury Center Milwaukee, Wisconsin
Adopting 540-Degree Fusion to Correct Cervical Kyphosis Anthony H. Sin, M.D., Rajesh Acharya, M.D., Donald R. Smith, M.D., and Anil Nanda, M.D., FACS Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, Louisiana Sin AH, Acharya R, Smith DR, Nanda A. Adopting 540-degree fusion to correct cervical kyphosis. Surg Neurol 2004;61:515–22. BACKGROUND
Two cases of severe cervical spine kyphotic deformity resulting from late effects of infection were successfully corrected by combined anterior and posterior instrumentations in a single operative sitting. CASE DESCRIPTION
Case 1 is a 43-year-old man who developed severe cervical kyphosis from C5-6 discitis over a few months despite long-term antibiotic therapy. He was neurologically intact except for severe neck pain and obvious deformity. Case 2 is a 40-year-old woman who had a previous wound infection five years before presentation. There was gradual worsening of swan neck deformity at the C2-3 and C5-6 levels with some spinal cord compression worsening her baseline myelopathy. The patients were placed and maintained in cervical traction on the Stryker frame for the duration of the procedure. Both cases required anterior approach initially to achieve some release of dense scar tissue using a high-speed drill. The wounds were then closed and patients were rotated to the prone position for further release of fused bony elements, including the facets. Lateral mass screws and plates were placed. In Case 2, additional instrument to the occipital was performed to stabilize the C2 using a U-shaped cervical rod. Once adequate reduction had been achieved, the patients were rotated back to supine position for further corpectomy and fibular construct fusion with plates. CONCLUSION
In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches. © 2004 Elsevier Inc. All rights reserved. KEY WORDS
Cervical spine, kyphosis, operative approach osteomyelitis, spine fusion.
Address reprint requests to: Anil Nanda, M.D., FACS, Professor and Chairman, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130 –3932. Received March 12, 2003; accepted June 2, 2003. © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
pinal osteomyelitis is uncommon, constituting 1% of all bony infections. The cervical spine is affected in only 3 to 6% of these, thus rendering it a clinically rare entity [8,10]. The vertebral body, which may be a primary site or involved secondary to invasion from the adjacent disk space, is involved in only about 8 to 16% of all pyogenic bone infections [2]. The initial clinical manifestation is non-specific, thereby delaying the diagnosis and often leading to vertebral body collapse, kyphosis, and neurologic deterioration. The management of severe kyphotic deformity is challenging, and the literature on this subject is scarce. We present two cases with severe kyphotic deformity complicating cervical osteomyelitis, which were managed successfully with 540-degree fusion with instrumentation.
S
Case Material CASE 1 A 43-year-old male presented with severe neck pain and progressive neck deformity of 3 months duration. There was no history of previous cervical problems or surgery. He had a significant history of IV heroin abuse. His neck pain worsened three months before presentation. The work-up done by his primary physician was consistent with C5-6 discitis and a long-term IV antibiotic therapy was initiated. Blood cultures grew Pseudomonas organisms although cultures taken from direct puncture site were negative. He continued to manifest neck pain and deformity despite medical therapy. The patient was referred to our institution for possible surgical intervention to correct the deformity. He denied any radiculopathy, numbness, weakness, gait difficulties, or bowel/bladder dysfunctions. Past medical history was negative for any heart disease, diabetes, cervical spine trauma, chronic steroid use, and hypertension. He had admitted to smoking 1.5 0090-3019/04/$–see front matter doi:10.1016/S0090-3019(03)00542-1
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Plain lateral view cervical X-rays in (A) flexion and (B) extension demonstrating severe destruction of C5-6 vertebra and almost 90-degree kyphosis at C5-6 level (Case 1).
packs of cigarettes per day and regularly consuming alcoholic beverages. Extension of the cervical spine was quite limited to the point that any gaze above the horizontal plane was possible only with marked over extension of the trunk. Examination of the motor and sensory system along with the gait was normal. Plain X-ray of the cervical spine, in flexion (Figure 1A) and in extension (Figures 1B), showed severe destruction of C5 and C6 vertebral bodies along with almost 90-degree kyphosis. Magnetic resonance imaging (MRI) of the cervical spine did not demonstrate any spinal cord involvement (Figures 2A, B), which was consistent with absence of neurologic deficit despite the marked deformity. The recommendation was made to surgically correct his cervical deformity. DESCRIPTION OF OPERATION The procedure comprised of three separate operative procedures carried out during a single session in the surgical suite. A Stryker frame allows for the constant application of skeletal traction during the repositioning of the patient in supine-prone-supine positions for
anterior-posterior-anterior surgical corrections. This repositioning sequence is called the 540-degree approach. Following general endotracheal anesthesia, Gardener-Wells tongs were applied to provide traction throughout the entire operative procedure. Because of the extreme degree of kyphosis, the patient’s head and chin were deformed in anterior flexion even with the traction. An oblique incision was made just anterior to the sternocleidomastoid muscle. We then performed a dissection from the anterior cervical region medial to the carotid sheath and its contents. Exposure was quite difficult because of the marked flexion deformity. The vertebral bodies at C5 and C6 were not visible anteriorly as the anterior inferior margin of C4 abutted the anterior superior surface of C7 (Figure 1A). We found thickened scar and fibrotic mass material in the region, but no obvious purulent material was found. A partial transverse resection of the longus colli muscles as well as removal of calcified scar tissues and residual bone with a high-speed drill allowed some relaxation of the deformity and straightening of the cervical spine. The posterior longitudinal
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Preoperative T2-weighted MRI images (A) sagittal and (B) axial views demonstrating severe kyphotic deformity without spinal cord compression (Case 1).
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(A) Postoperative plain X-rays showing good resolution of kyphosis with adequate placement of instrumentations and (B) alternate view (Case 1).
ligament was identified after further resection of portions of the C5 and C6 bodies as widely as possible under direct visualization with the operating microscope. The majority of deformity persisted because of posterior element fixation. The anterior wound was packed and closed to proceed unto the second procedure from the posterior approach. After rotating the patient in a prone position, skin incision from inion to C7 spine was made. The muscular and ligamentous attachments were separated and C5-6 spinous processes were identified. The facets at C4-5 and C5-6 were fused and immobile. The lamina, posterior facets, and lateral masses of C5 were radically removed with the high-speed drill to free these fusions. After the lateral bony masses of C5 had been removed, there was a greater visible reduction of curvature. When this reduction was complete, there was approximation of the spinous processes of C4 and C6. The lateral mass screws were placed at the levels of C4, C6, and C7 using C-arm fluoroscopy (Figure 3A). The posterior rods were then fitted to the desired contour and secured to the bone with lateral mass screws allowing further reduction to the cervical curvature. Additional
morcellized bone fragments from the spinous processes and bone dust salvaged from the corpectomy were then packed laterally at the site where the facets had been decorticated. The wound was closed in multiple layers after copious irrigations. The last stage was instrumentation anteriorly in the supine position. Upon reopening the anterior wound, there had been a remarkable reduction in the cervical deformity and the corpectomy of C5 and C6 was complete. The inferior surface of C4 and superior surface of C7 were decorticated and a slight recess was placed in each as the receptacle for the bone graft using the high-speed drill. A fibular strut was placed to bridge the defect, and the bone marrow cavity was packed with bone dust from the corpectomy. An anterior plate was selected of an appropriate length to bridge from C4 to C7. This plate was then placed and secured to C4 and C7 with 2 screws each (Figure 3B). Two intermediate screws were placed into the fibular graft through previously drilled holes in the graft and prepared by tapping. Following intraoperative radiographic confirmation, the wound was closed. The patient was monitored throughout this proce-
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Plain X-rays showing severe kyphosis with subluxation at C2-3 levels (Case 2).
dure with evoked potentials and they remained stable during the entire case. At the close of the procedure, the Gardener-Wells skeletal tongs were removed and replaced with a Miami-J hard collar. CASE 2 A 40-year-old female had developed quadriplegia following a motor vehicle accident in 1985. She had previously undergone a posterior laminectomy and fusion at another medical center. She was later referred to us because of worsening symptoms in her right side with worsening spasticity and pain over the last few years and obvious deformity in her cervical spine. The radiographic studies showed swan neck deformity at C2-3 and C4-5 and the fixed deformity at the fused segment (Figure 4). In view of the worsening neurologic status, surgery to alleviate her symptoms and surgically correct the deformity to halt further deterioration was planned (Figure 5). For the C5 burst fracture, she underwent C5 corpectomy with iliac graft fusion. Her postoperative course was complicated by infection at the operative site requiring open drainage of the wound and antibiotics. She improved significantly, but was stable with a residual right upper extremity paresis and spasticity in the lower extremities.
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DESCRIPTION OF OPERATION After oral general endotracheal anesthesia, GardenerWells tongs were applied providing 15 lbs traction throughout the operative procedure. An oblique incision was made immediately anterior to the sternocleidomastoid muscle followed by further dissection down to the anterior cervical region medial to the carotid sheath and its contents. The entire anterior vertebral bodies from C2 to C7 were exposed. The deformities involved upper cervical levels warranting a radical corpectomy of the anterior fused C4, C5, and C6 segments. The removal of the bone continued in the bone graft area until the posterior longitudinal ligament and dura were visible. Using a high-speed drill we laterally cut through the bone until the entire bony segment had been bilaterally sectioned allowing only a slight reduction of the kyphotic deformity. The surgical site was then packed and skin was closed to proceed with the second part of the operation posteriorly. In the prone position, a vertical skin incision from the occipital region to T1 level was made. A solid bony fusion was noted bilaterally incorporating C4, C5, and C6. Marked anterior listhesis of the facet joints were noted at C2-3 and C3-4. Along with extensive laminectomies, multi level facet joint removal was performed with the high-speed drill. The fused bone was divided laterally into separate segments to allow further reduction of the kyphosis with instrumentation. A cervical rod was contoured in a U-shape with a slight lordotic curve. The lateral mass screws were placed bilaterally at C3 and approximately C5 and C7. Once the screws were in place, the rod was connected to the screws. Sublaminar wires were placed underneath the C2 lamina bilaterally and twisted about the superior portion of the rod loop to draw the superior segments of the cervical spine posteriorly and effect some reduction in the kyphotic curve. After all the screws were tightened, a considerable reduction in the kyphotic deformity and essential straightening of the cervical spine was achieved. The incision was closed in multiple layers of cervical muscle fascia, subcutaneous tissue, and skin. The patient was placed back into the supine position for the final stage. The incision was reopened, and retractor was replaced to distraction. A fibular graft was taken and contoured to fit snugly between the inferior portion of C2 to the superior portion of C7. A plate was selected to fit from C2 to C7 level. Two screws were placed each in C2 and C7 bodies and a single screw in the fibular graft. Bone dust from the drill was packed about this graft, and the marrow cavity of the fibular strut had been previ-
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T2 weighted sagittal MRI images demonstrating kyphosis with spinal cord compression (Case 2).
ously filled with this same material. At the completion of the operation, the skeletal tongs were removed and a Philadelphia collar was placed.
Results Case 1 recovered well from the procedure without any neurologic deficits and was discharged 5 days later. At the 60-day, postsurgical follow-up, the patient was pain free without any medication and neurologically intact. The patient’s immediate postop and 60-day X-rays were comparatively unchanged (Figure 3B). Case 2 recovered well from the procedure without any signs of worsening of the neurologic status (Figure 6A). Her strength in both sides was the same as the baseline, but she required some rehabilitation for gait training. She had been unable to ambulate before surgery secondary to her deformity and severe pain. At 12 months follow-up, the spinal alignment and fusion have been satisfactory without the cervical collar (Figure 6B). The patient is ambulating with only a mild gait spasticity.
Discussion Cloward suggested multiple factors leading to disk space infection with or without associated vertebral osteomyelitis. These include iatrogenic infections following: (1) disc operations, (2) discography, and (3) other injections delivered adjacent to the spine (1). Increased incidence of sepsis in hospitalized patients is another factor responsible for some of these cases. Individuals with diabetes mellitus, chronic steroid therapy, renal failure, and systemic infection are believed to be at a higher risk for developing spinal infections [7]. Although the prevalence of spinal infection involving the cervical level is lower than the lumbar or thoracic levels, the risk of developing neurologic deficit with such infections of the cervical area is much higher because of limited spinal canal space compared to other levels [8]. The anterior portion of the vertebral body is involved more frequently than the posterior elements. The scarring and contracture in this area may result in a kyphotic deformity [11]. The leading organism for spinal infection is Staphylococcus aureus. The emergence of IV drug abuse in recent years is another prominent factor leading to many such infections [8,3].
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(A) Immediate and (B) 6 months postoperative plain X-rays showing improved alignment of the spine (Case 2).
The presence of severe neck pain, especially in a febrile patient, should arouse the suspicion of cervical osteomyelitis. This is especially true if of the patient has one of the above mentioned predisposing factors [10]. The majority of spinal infections are treated successfully with IV antibiotics when diagnosed promptly and if the therapy is initiated with appropriate coverage for the organism. Once an infectious etiology is suspected or has been proven with positive blood cultures and/or tissue diagnosis, the usual recommended treatment is 4 – 6 weeks of IV antibiotics concurrently with an external spinal orthotic device. Surgical intervention is warranted in the presence of (1) neurologic deficits secondary to compression from epidural collection or kyphosis; (2) prevertebral collection causing severe pain and pressure; (3) progressive kyphotic deformity [1,10]. The goals of surgery in cervical osteomyelitis may include: decompression of the neural elements, collection of tissue for pathologic analysis and culture, debridement of destroyed vertebral bodies and stabilization by performance of fusion. Most of the cases of cervical osteomyelitis described in the literature have been managed by anterior debridement and fusion [1,10]. Only anec-
dotal cases of combined anterior as well as posterior approaches have been found [1,10]. In these 2 patients reduction of the severe deformity required a combined approach with progressive release of the fused elements both anterior and posterior to allow satisfactory alignment. The combined approach also spares the patient the necessity of having a second or third separate major procedure. Both patients were discharged on fifth postoperative day, which illustrates the reduced duration of hospital stay with the substantial decrease in overall cost of this complex treatment. The first patient had positive blood cultures for Pseudomonas organisms, but the actual tissue culture sent from a needle aspiration had failed to grow any organisms. This is not unexpected after a long duration of antibiotic therapy [3]. This patient’s spinal alignment deteriorated rapidly, despite aggressive medical therapy for several months. Fortunately, he remained devoid of neurologic deficits though the radiographic studies revealed extreme kyphosis. The second patient had an infection more than 10 years before this presentation. Before surgery her baseline neurologic function was declining with progression of the kyphosis.
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The operation relieved much of her pain but also improved her spasticity and strength. These 2 cases illustrate combined anterior and posterior instrumentation to correct severe kyphosis complicating cervical osteomyelitis. Surgical intervention with evacuation and stabilization at an earlier phase of the infection, at the first sign of clinical deterioration or at no response to the medical treatment would have prevented such a high degree of deformity. The infections involved compression of vertebral bodies and fusion of the cervical spine at multiple levels resulting in a debilitating kyphotic position at the time of presentation to our institution. The severe deformities in these patients failed to reduce the kyphosis despite concurrent skeletal traction in initial anterior approach and subsequent corpectomies. Even after anterior release had been accomplished, the kyphosis remained relatively fixed because of associated fusion between the posterior elements of adjacent segments. This fixation required associated release from the posterior approach. Segmentation of the fused segment bilaterally with the high-speed drill was required to attain reasonable reduction of the abnormal curvature. The second case involved a higher cervical level than the first case, and required inclusion of C2 in the instrumentation posteriorly in the form of sublaminar wires. Finally, when both anterior and posterior release had been accomplished, the instrumentation and fixation could be accomplished. After completion of the posterior instrumentation, the patient was rotated back into supine position for a fibular strut and plate anteriorly. Both patients had excellent clinical as well as radiographic results.
Conclusion The occurrence of chronic neck pain in immunocompromised patients, or patients with a recent history of spinal surgery, drug abuse, and diabetes should be viewed as highly suspicious and evaluated for possible infections. In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches. This allows complete release of both anterior and posterior fixation. It also avoids the risk of a second surgery, shortens the duration of hospital stay and reduces the costs incurred. REFERENCES 1. Cloward RB. Metastatic disc infection and osteomyelitis of the cervical spine. Spine 1978;3(3):194 –201.
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2. Garcia A, Granthal SA. Hematogenous pyogenic vertebral osteomyelitis. J Bone Joint Surg 1960;42A:429. 3. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25(13):1668 – 79. 4. Levi AD, Dickman CA, Sonntag VK. Management of postoperative infections after spinal instrumentation. J Neurosurg 1997;86(6):975–80. 5. Liebergall M, Chaimsky G, Lowe J, Robin GC, Floman Y. Pyogenic vertebral osteomyelitis with paralysis. Prognosis and treatment. Clin Orthop 1991;269:142– 50. 6. Malik GH, Crawford AH, Halter R. Swan-neck deformity to osteomyelitis of the posterior elements of the cervical spine. J Neurosurg 1979;50:388 –90. 7. Messer HD, Litvinoff J. Pyogenic cervical osteomyelitis. Arch Neurol 1976;33:571–6. 8. Schimmer RC, Jeanneret C, Nunley Jeanneret B. Osteomyelitis of the cervical spine. J Spinal Disord Tech 2002;15(2):110 –7. 9. Stone DB, Bonfiglio N. Pyogenic vertebral osteomyelitis. Arch Intern Med 1963;112:491–500. 10. Stone JL, Cybulski GR, Rodriguez J, Gryfinski ME, Kant R. Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine. J Neurosurg 1989;70:879 –83. 11. Wiley AM, Trueta J. The vascular anatomy of the spine and its relationship to pyogenic vertebral osteomyelitis. J Bone Joint Surg 1959;41B:796 –809.
COMMENTARY
The authors have provided a valuable service in presenting 2 very interesting cases of cervical kyphosis managed through a front/back/front approach (540-degree fusion). Clearly such an aggressive process is necessary for the correction of severe cervical kyphosis, as is shown. The question, however, is whether correction of deformity is essential. Certainly, the pain would likely be improved if the deformity is reduced from the 40- to 50-degrees minimum evident to a much more physiological alignment. Secondly, the distortion of the spinal cord will be further reduced. One caution: we generally recommend fixation being performed at least one level above the deformity. Thus, in the first case, we probably would have placed the posterior screws at least into C3. In the second case, with wire going into C2, it would have been tempting to take fixation up higher to improve healing. However, despite these possible technical issues, the procedure described by the authors should be in the armamentarium of those managing complex cervical deformities. Dennis J. Maiman, M.D., Ph.D. Spinal Cord Injury Center Milwaukee, Wisconsin