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Cervical kyphosis


Introduction

The cervical spine, which was first described as lordotic by Borden et al. in 1960, is tasked with the responsibility of maintaining a wide range of motion, and allowing proper gaze that is essential for upright gait. The cervical spine also absorbs the torsional, axial, and shear loads exerted by the cranium and more rigid thoracic spine, which serves a crucial role in maintaining normal day-to-day function. Although misalignment of spinopelvic parameters may play a role in back pain and disability, there has been less consistent evidence to support similar findings in the cervical spine. It is reported that up to 30% of the general population may have kyphosis of the cervical spine although the ramification of this is unclear. While there is evidence suggesting a portion of the population may live with cervical kyphosis without adverse symptoms, many others have reported on the effects of cervical sagittal parameters on axial neck pain and degenerative effects on cervical disks. Additionally, many authors have found that cervical sagittal misalignment has been found to be an independent predictor of disability, higher neck disability index (NDI), and severity of myelopathy. The role of cervical kyphosis in radicular pain is limited as this is due to focal pathology, which can be addressed by intervention addressing the underlying cause of the radicular pain.

Example case

  • Chief complaint: neck pain and radiculopathy

  • History of present illness: A 48-year-old male with progressive neck pain and right arm pain in C5 and C7 distributions that has been unresponsive to physical therapy, steroid injections, and spinal manipulations. This pain has progressed over the past 2 weeks and he underwent imaging of his cervical spine ( Figs. 39.1 – 39.2 ).

    Fig. 39.1, Preoperative magnetic resonance imaging. (A) , T2 sagittal and (B) , T2 axial images demonstrating disc degeneration and foraminal stenosis at the right C4-5 with a disc herniation at C6-7 causing nerve root compression and cord compression on the right side.

    Fig. 39.2, Preoperative x-rays. (A) , Lateral and (B) , anteroposterior images demonstrating cervical kyphosis and loss of normal cervical lordosis.

  • Medications: acetaminophen

  • Allergies: no known drug allergies

  • Past medical and surgical history: depression, anxiety, obesity, appendectomy

  • Family history: noncontributory

  • Social history: smokes one pack per day, drinks one alcoholic beverage per day

  • Physical examination: awake, alert, andoriented to person, place, and time; cranial nerves II–XII intact, decreased cervical range of motion; bilateral deltoids/triceps/biceps 5/5 except right deltoid 4/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

  • Benjamin D. Elder, MD, PhD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Alugolu Rajesh, MD

  • Neurosurgery

  • Nizam’s Institute of Medical Sciences

  • Punjagutta, Hyderbad, India

  • K. Daniel Riew, MD

  • Orthopaedic Surgery

  • Columbia University

  • New York, New York, United States

  • Luiz Robert Vialle, MD

  • Orthopaedic Surgery

  • Pontifical Catholic University of Parana

  • Curitiba, Brazil

Preoperative
Additional tests requested

  • Flexion-extension cervical x-rays

  • DEXA

  • Right C4-5 transforaminal epidural injection

  • Right C5-6 transforaminal epidural injection

  • Physical therapy with traction

  • CT C-spine

  • Respiratory evaluation

  • Anesthesiology evaluation

CT cervical spine

  • Physical therapy with cervical traction

  • Nerve root injections

Surgical approach selected If meets all criteria (fails nonoperative management, negative nicotine test), C4-5 and C6-7 ACDF C4-5 and C6-7 ACDF C4-5 ACDF and C6-7 ACDF If fails with conservative management, C4-5 ACDF with anchored cages

  • Surgical approach if 21

  • Surgical approach if 80

  • Possible cervical arthroplasty

  • Same

  • Possible cervical arthroplasty

  • Conservative management

  • C4-5 and C6-7 ACDA

  • C4-7 ACDF

  • Disc replacement

  • Same

Goal of surgery Decompress right C5 and C7 nerves, increase lordosis, stabilize spine Decompress spinal cord at C4-5 and right C7 nerve root, stabilization and fixation Relief of weakness in arm and pain in arm and neck Decompress index level
Perioperative
Positioning Supine on flat Jackson table with Gardner-Wells tongs and 10 lb of traction Supine Supine Supine
Surgical equipment

  • Fluoroscopy

  • IOM (MEP/SSEP)

  • Surgical microscope

  • Retractor system

  • Distraction pins

  • IOM (MEP)

  • Fluoroscopy

  • Surgical microscope

  • Fluoroscopy

  • Surgical microscope

  • Wired tracheal tube

  • Nasopharyngeal tube

  • Fluoroscopy

Medications None None Steroids, gabapentin None
Anatomical considerations Carotid sheath, recurrent laryngeal nerve, esophagus, vertebral arteries Carotid sheath, trachea/esophagus, thyroid, recurrent laryngeal nerve, index levels, vertebral arteries, dura, spinal cord Trachea, esophagus, carotid sheath contents, longus colli, uncinate processes, foramen, vertebral artery, nerve root Carotid artery, esophagus, vertebral artery
Complications feared with approach chosen Neck hematoma, hoarseness, swallowing dysfunction, C5 palsy, pseudoarthrosis, degeneration of C5-6 disc space, CSF leak, kyphosis Injury to carotid sheath contents, trachea/esophagus, thyroid gland, recurrent laryngeal nerve, vertebral arteries, spinal cord Adjacent level reoperative, pseudoarthrosis Esophageal fistula
Intraoperative
Anesthesia General General General General
Exposure C4-6 C4-7 C4-7 C4-5
Levels decompressed C4-6 C4-7 C4-5, C6-7 C4-5
Levels fused C4-5, C6-7 C4-5, C6-7 C4-5, C6-7 C4-5
Surgical narrative Position supine on flat Jackson table with gel axillary roll transversely across shoulders, 10 lb of traction, tape shoulders down, fluoroscopy for preoperative localization to position incision over C6 vertebral body in neck crease, left-sided transverse neck incision, mobilize esophagus medially and carotid sheath laterally, place distraction pins into vertebral body for localization, mobilize longus colli off vertebral bodies, place retractor system and 14 mm distraction pins in C4 and C5, remove C4-5 disc and PLL, place frozen structural allograft and anterior plate, repeat procedure at C6-7, obtain final x-rays, leave drain in retropharyngeal space Position supine in neutral lordosis, oblique skin incision over anterior border of right sternocleidomastoid from C3 to sternal notch, platysma incised along with skin, subplatysmal dissection and identification of fascial plane medial to sternocleidomastoid is developed, retract carotid sheath laterally and trachea/esophagus medially, fascial dissection deepened, inferior belly of digastric is identified and cut sharply and sutured at the end, identify longus colli and midline, identify C4-5 and C6-7 levels with x-ray, incise longus colli and prevertebral fascia at above cranial then caudal levels, disc space distracted with disc space distracted with pins, discectomy with cutting PLL sharply to expose dura, end plate preparation until punctate bleeding noted, spacer filled with cancellous bone graft secured with median screws at both levels, layered wound closure with drain Position supine, standard Smith-Robinson approach, fluoroscopy to confirm levels, perform discectomy at C4-5 first, right uncinatectomy, maintain PLL, place allograft with BMP and anterior plate, anterior cervical discectomy at C6-7 but go through PLL, place prosthesis, closure in layers Position supine, approach on right, meticulous dissection, remove nasopharyngeal tube to avoid compression with retractors once esophagus localized, avoid static retractors, use small manual retractors with less pressure over structures, fluoroscopy to determine correct level, C4-5 discectomy using Caspar distractors, open PLL for intracanal disc removal, cage test and size selection, cage filled with allograft bone, place cage and anchor with three or four screws, depending on the model
Complication avoidance Increase neck extension with gel axillary roll, left-sided approach to decompress right foramen and minimize injury to recurrent laryngeal nerve, distraction pin in vertebral body for localization, start with more symptomatic level Oblique skin incision to maximize exposure, cut PLL to expose dura, end plate preparation until punctate bleeding noted Right uncinatectomy at C4-5, BMP to promote fusion, place arthroplasty at C6-7 to preserve motion Right-sided approach to minimize laryngeal nerve injury, meticulous dissection to avoid laryngeal nerve injury, nasopharyngeal tube to help identify esophagus, avoid static retractors to minimize risk of dysphagia or dysphonia
Postoperative
Admission Floor ICU Outpatient Floor
Postoperative complications feared Swallowing dysfunction, hoarseness, neck hematoma, C5 palsy Hematoma, neurological deterioration, recurrent laryngeal nerve palsy, wound infection Pseudoarthrosis, hematoma, swelling, dysphagia, dysphonia Unlikely but bleeding, dysphagia, dysphonia
Anticipated length of stay Overnight 1–2 days Same day Overnight
Follow-up testing

  • C-spine AP/lateral x-rays after surgery, 6 weeks, 3 months, 6 months after surgery

  • CT C-spine 12 months after surgery

C-spine x-ray within 6 hours, every 3 months after surgery

  • Standing AP and lateral x-rays prior to discharge

  • C-spine flexion-extension and neutral lateral x-rays at 6 weeks, 6 months, 12 months after surgery

C-spine x-rays 30 days, every 2 months until 6 months after surgery
Bracing None None Hard collar for 6 weeks Soft collar for comfort for 2 weeks
Follow-up visits 6 weeks and 12 months after surgery 4 weeks and every 3 months after surgery 6 weeks, 6 months, 12 months after surgery 30 days, every 2 months until 6 months after surgery
ACDF , Anterior cervical decompression and fusion; AP , anteroposterior; BMP , bone morphogenic protein; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Cervical kyphosis

  • ▪

    Cervical scoliosis

  • ▪

    Torticollis

  • ▪

    Cervical stenosis

  • ▪

    Cervical radiculopathy

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