Case report
Post-traumatic cervical kyphosis with surgical correction complicated by temporary anterior spinal artery syndrome

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Summary

Post-traumatic undiagnosed disco-ligamentous and osseous lesions of the cervical spine may eventually result in irreducible extreme kyphosis. Correction of such consolidated deformities requires major surgery with a combined posterior and anterior approach, aiming to correct bony impingement on neural and vascular structures, reduce deformity and to attain circumferential instrumentation and fusion in physiological alignment. This can be achieved using either a single-staged or a two-staged procedure. Regardless, this type of major surgery entails considerable neurological risks. Therefore, thorough planning of the intervention and considerable surgical experience is needed. We present an elderly woman with gross restriction of forward gaze and intractable nuchal and radicular pain due to cervical spine deformity. Her cervical kyphosis was corrected using preoperative skeletal axial traction for four days and subsequent operative reduction with circumferential instrumentation and fusion. The post-operative course was complicated by a temporary anterior spinal artery syndrome despite normal intraoperative somatosensory evoked potentials (SSEP) and by a wound infection requiring removal of the implant. Nevertheless, segmental fusion in physiological alignment was successfully achieved and the patient fully recovered from the neurological deficit and infection. Quality of life was significantly improved.

Introduction

Development of regional irreducible kyphosis may occur after undiagnosed and untreated traumatic disco-ligamentous and osseous lesions of the cervical spine.[1], [2] Thus, extreme rigid cervical kyphosis can be the late result of inadequate primary diagnostic work-up, incorrect assessment of initial spinal instability or inappropriate treatment.3 In such cases progressive cervical kyphosis may eventually result in painful fixation of the head in extreme flexion, impeding forward gaze and jaw movements (chin-on-chest deformity).[4], [5] These patients may develop compressive myelopathy very similar to that of individuals with kyphotic deformities of other origins.[4], [6], [7], [8]

In these deformities, posterior and anterior osteotomy with decompression of neural structures is required in order to reconstruct cervical lordosis.[1], [5], [7], [9] Both one-stage and two-stage interventions represent major surgical procedures [1], [4], [5], [6] and entail considerable neurological risks.

It is the aim of this report:

  • 1.

    To raise the index of suspicion of significant instability even with normal cervical alignment in the elderly presenting after minor cervical trauma.

  • 2.

    To present the surgical management of a case of post-traumatic extreme cervical kyphosis.

  • 3.

    To highlight a specific neurological complication which may occur during reconstruction of physiological cervical lordosis.

Section snippets

History and clinical findings

This 75-year-old woman with cervical diffuse idiopathic skeletal hyperostosis (DISH) disease sustained a fall on a staircase. Diagnosis was of C6 compression fracture with anterolisthesis of C5 on C6. There was no neurological deficit. She underwent non-surgical management with a soft orthosis only. Within six months, extreme C5/C6 kyphosis developed (Fig. 1). She was no longer able to extend or to turn her head. As her head was fixed in this extreme flexed position, she had significant

Discussion

The initial emergency room assessment of this patient revealed traumatic cervical bony lesions that were considered to be of minor importance. As the physiological lordotic alignment of the cervical spine was preserved and there was no dislocation of the articular processes, the severity of the trauma was underestimated.3 Fractures of the articular processes and anterior parts of the vertebral bodies, as well as disco-ligamentous lesions are the most common causes of development of

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