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Cervical Spine Deformity: Indications, Considerations, and Surgical Outcomes Review Article Cervical Spine Deformity: Indications, Considerations, and Surgical Outcomes Abstract Samuel K. Cho, MD Cervical spinal deformity (CSD) in adult patients is a relatively Scott Safir, MD uncommon yet debilitating condition with diverse etiologies and clinical manifestations. Similar to thoracolumbar deformity, CSD can Joseph M. Lombardi, MD be broadly divided into scoliosis and kyphosis. Severe forms of CSD Jun S. Kim, MD can lead to pain; neurologic deterioration, including myelopathy; and cervical spine–specific symptoms such as difficulty with horizontal gaze, dysphagia, and dyspnea. Recently, an increased interest is shown in systematically studying CSD with introduction of classifi- cation schemes and treatment algorithms. Both major and minor complications after surgical intervention have been analyzed and juxtaposed to patient-reported outcomes. An ongoing effort exists to From the Department of Orthopaedic better understand the relationship between cervical and Surgery (Dr. Cho and Dr. Kim), the thoracolumbar spinal alignment, most importantly in the sagittal Department of Vascular Surgery (Dr. Safir), Icahn School of Medicine at plane. Mount Sinai, and the Department of Orthopaedic Surgery (Dr. Lombardi), Columbia University Medical Center, New York, NY. ervical spinal deformity (CSD) Etiology Dr. Cho or an immediate family Cremains a moving target in member serves as a paid consultant the current spine literature. It is a to Corentec, Globus Medical, potentially debilitating condition Congenital Medtronic, and Zimmer Biomet; has Atlanto-occipital fusion, os received research or institutional with numerous etiologies, such as support from Zimmer Biomet; and iatrogenic, inflammatory arthropathy, odontoideum, and basilar invagi- serves as a board member, owner, spondylosis, congenital, neuromuscu- nation are atlas and axis anomalies officer, or committee member of the lar, traumatic, infectious, and neuro- thatcanleadtoCSD.Klippel-Feil American Academy of Orthopaedic syndrome, which causes most of the Surgeons, the American Orthopaedic muscular processes. Severe cervical Association, the AOSpine North instability or sagittal malalignment can subaxial cervical congenital defects, America, the Cervical Spine Research lead to pain; neurologic deterioration, involves fusion of cervical verte- Society, the North American Spine including myelopathy; and cervical brae (Figure 1). Achondroplasia, the Society, and the Scoliosis Research – common skeletal dysplasia, can lead Society. None of the following authors spine (CS) specific symptoms such as or any immediate family member has difficulty with horizontal gaze, dys- to posterior vertebral scalloping, short received anything of value from or has phagia, and dyspnea. Recent efforts pedicle canal stenosis, laminar thick- stock or stock options held in a have sought to classify CSD and for- ening, and widening of intervertebral commercial company or institution disks. Down syndrome is linked to related directly or indirectly to the mulate treatment algorithms. In this subject of this article: Dr. Safir, review, we discuss the anatomy, ligamentous laxity that causes cervical Dr. Lombardi, and Dr. Kim. pathophysiology, and common etiol- instability seen at both the atlanto- J Am Acad Orthop Surg 2019;27: ogies of CSD. We then describe pos- axial joint and occiput-C1 level. e555-e567 sible treatments, which are as myriad DOI: 10.5435/JAAOS-D-17-00546 as the etiologies of CSD. Finally, we discuss the outcomes of CSD in the Traumatic Copyright 2018 by the American Academy of Orthopaedic Surgeons. literature and its relationship to thor- CSD can result from instability sec- acolumbar deformity (TLD). ondary to trauma. Upper CS injuries June 15, 2019, Vol 27, No 12 e555 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Cervical Spine Deformity Figure 1 A, Preoperative AP and lateral radiographs of the cervical spine demonstrating kyphoscoliosis in an adult patient with Klippel-Feil syndrome. B, MRI of the cervical spine showing stenosis. C, Postoperative AP and lateral radiographs of the cervical spine after C2-T3 circumferential reconstruction. include occipitocervical dislocation, posttraumatic CSD develops do so Spondylosis and occipital condyle fractures, atlas frac- because of nonunion, implant fail- Degenerative Disk Disease tures, atlanto-axial rotatory instability ure, Charcot joint, or technical Disk degeneration leads to increased (AAI), atlanto-dens instability, and error after surgery for the injury.1 mechanical stress at the cartilaginous odontoid fractures. Subaxial injuries Injuries involving the posterior end plates at the vertebral body (VB) include traumatic spondylolisthesis ligamentous structures, such as lip. Generally, spondylosis begins of axis (Hangman’s fracture), flexion advanced-staged burst flexion- injuries, vertical compression in- compression or flexion-distraction with intervertebral disk desiccation, juries, and subaxial extension in- injuries, are prone to deformity leading to bulging of the anulus fi- juries. Posttraumatic CSD develops overall (Figure 2), whereas lateral brosus, loss of height anteriorly, and a in most patients because of the compression or burst injuries can positive feedback loop of increased trauma itself, but interestingly, result in posttraumatic coronal or anterior weight bearing leading to a minority of patients in whom a scoliotic deformities.1 cervical kyphosis (CK)2 (Figure 3). e556 Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Samuel K. Cho, MD, et al Spondylosis is also associated with Figure 2 ossification of the posterior longitu- dinal ligament, which can contribute to ventral cord compression. This often leads to loss of lordosis in the subaxial spine and can negatively influence global sagittal alignment (GSA). Patients will often hyperextend through their high CS (occiput-C2) to compensate for the loss of subaxial segments. By contrast, pure scoliotic deformity is rarely from spondylosis. Inflammatory Rheumatoid arthritis (RA) is the most common inflammatory disorder that can affect the CS. The prevalence of CS involvement in RA ranges from Chronic flexion-distraction injury leading to angular kyphotic deformity in the 25% to 80%, depending on the algo- subaxial cervical spine. This patient successfully underwent C2-T1 rithm used,3 with seropositivity as a circumferential spinal fusion with correction of deformity. major risk factor. The three typical RA deformities in the CS are, in order of decreasing frequency, AAI or posterior cervical muscles, causing Postoperative development of insta- subluxation, superior migration of atrophy, and disruption of facet bility because of removal of static and the odontoid process, and subaxial joints may lead to instability. dynamic stabilizing soft-tissue struc- subluxation. Removal of the posterior tension tures and facet violation is a well- Seronegative spondyloarthropathies band leads to worsening compres- known complication, and it was a include ankylosing spondylitis (AS), sive forces on the anterior VB, thus major stimulus to the use of laminec- Reiter’s syndrome, psoriatic arthritis, exacerbating sagittal deformity and tomy with instrumented fusion and and enteropathic arthritis. AS is the causing a kyphotic angulation.4 laminoplasty. The literature compar- most common of the seronegative The incidence of iatrogenic CSD is ing outcomes of laminoplasty versus disorders and will affect the CS later in difficult to measure because of hetero- laminectomy are disparate, likely sec- the disease course. Common mani- geneity of patient and case complexity. ondary to the heterogeneity between festations in the CS are CK and AAI. One case series demonstrated a 45% surgeon technique and patient as well Global spinal kyphosis progresses as a incidence in patients without any pre- as radiographic characteristics.9,10 It means to offload painful facet joints, operative instability.5 Contrarily, can be agreed on, however, that the and autofusion in this abnormal sag- postoperative kyphosis developed in progression of loss of lordosis to ittal alignment leads to a fixed flexion 10.6% of patients undergoing lam- kyphosis after laminoplasty appears deformity. Furthermore, susceptibility inoplasty for cervical spondylosis, to be dependent on the technique. to spinal fractures leads to frequent ossification of the posterior longitu- Invariably, the preservation of muscle and missed fractures that can worsen dinal ligament, and multilevel disk attachments has been shown to be the existing deformity. herniation.6 A retrospective analysis essential for maintaining sagittal cer- investigating the incidence and out- vical alignment. The posterior cervical Iatrogenic comes of kyphotic deformity after approach requires careful exposure Iatrogenic (postoperative) remains laminectomy for cervical spondylotic from C3 to C7 while taking care to the most common cause. Typically, myelopathy determined that kyphosis dissect in the avascular plane, or the postoperative CK is associated may develop in 21% of these patients.7 raphe, between the left and the right with a previous laminectomy or In the pediatric population, weaker paraspinal musculature. Additionally, laminoplasty and demonstrates a musculature, ligamentous elasticity, during exposure of the lateral masses, loss of sagittal alignment,
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