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CHAPTER 125 Christopher G. Furey Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity The author would like
CHAPTER 125 Christopher G. Furey
CHAPTER
125
Christopher G. Furey

Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity

Extension Osteotomy for Chin-On-Chest Deformity The author would like to acknowledge the assistance and
Extension Osteotomy for Chin-On-Chest Deformity The author would like to acknowledge the assistance and

The author would like to acknowledge the assistance and guid- ance of Dr. Henry Bohlman who pioneered the use of cervico- thoracic osteotomy in the treatment of fixed kyphotic deformities. Dr. Bohlman’s foresight and skill, as well as his commitment to education, have had untold influence on the care of patients with spinal disorders.

INTRODUCTION

A fixed kyphotic deformity of the cervicothoracic spine result- ing in chin-on-chest deformity is an uncommon although severely disabling condition. Surgical correction with a poste- rior cervicothoracic extension osteotomy can provide dramatic restoration of head and neck posture and marked relief of pain and improvement in function (Tables 125.1 and 125.2). The goals of an extension osteotomy are to improve sagittal align- ment and to restore the head to a more normal position in relation to the thoracic spine. The successful cervicothoracic extension osteotomy allows for improved forward gaze resulting in more functional ambu- lation, relief of spinal cord compression and nerve root trac- tion, relief of dysphagia and dyspnea from kinking of the esophagus and trachea, respectively, and prevention of atlanto- axial subluxation by eliminating the biomechanical stress from the head being carried in a forward position.

ETIOLOGY

Fixed chin-on-chest deformities are most commonly seen in patients with ankylosing spondylitis. The primary flexion defor- mity (fixed hyperkyphosis) in patients with ankylosing spon- dylitis occurs most commonly in the thoracic and lumbar spine but occasionally will primarily involve the cervicothoracic spine. The chin-on-chest deformity results in problems with horizon- tal gaze, gait, swallowing, personal hygiene, and neck pain and may be accompanied by varying degrees of myelopathy due to draping of the spinal cord over the kyphotic spinal column. The deformity in ankylosing spondylitis may occur at any age and may be associated with deformities in the thoracic and lumbar spine. As the deformity reaches approximately 45°, the mere weight of the head will pull the cervical spine into increas-

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WBK836_Ch125_p1345-1354.indd 1345 1345 ing kyphosis. The bone of the ankylosed spine is a living

ing kyphosis. The bone of the ankylosed spine is a living struc- ture and will progressively remodel into the kyphotic position until, in the most extreme case, the chin comes to rest upon the sternum. Alternatively, the deformity may occur after a fracture of the ankylosed cervical spine, with subsequent development of a severe fixed kyphosis. Other conditions such as postlaminectomy or posttraumatic cervical kyphosis are less likely to result in a chin-on-chest deformity. In these conditions, the deformities are generally not as large or as rigid as those seen with ankylosing spondylitis and less often require osteotomies for correction. In patients with advanced spondylotic changes and longstanding muscle contractions, however, a fixed deformity may arise similar to those in patients with ankylosing spondylitis.

SURGICAL INDICATIONS

Patients with a chin-on-chest deformity typically have experi- enced longstanding pain and disability. Indications for surgery include severe neck pain, altered function, limited lifestyle, and progressive deformity. As deformities approach 45°, activities of daily living and personal hygiene become increasingly difficult. The ability to safely ambulate is limited as patients have diffi- culty looking forward, even with compensation through pelvic retroversion and knee flexion. In extreme cases, patients may have difficulty feeding themselves. While there is not a specific numeric threshold for the degree of sagittal deformity at which surgery becomes abso- lutely indicated, once a deformity is greater than 45°, surgical intervention should be considered, as it is at this point a patient is likely to experience significant symptoms and functional lim- itations. Progressive kyphosis on serial radiographic examina- tions is also an indication for surgery and is commonly seen in the patient with ankylosing spondylitis, as the bone of the spi- nal column continues to remodel under the weight of the head. It is desirable to correct a deformity before it has progressed to the point where the chin is directly resting on the chest. Sagittal alignment is a regional measurement made between lines per- pendicular to an upper cervical vertebral end plate (C2 or 3) and a midthoracic vertebral end plate. Successive measure- ments should be made at identical levels to correctly assess deformity progression.

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be made at identical levels to correctly assess deformity progression. 1345 8 8/26/11 /26/11 5 5:42:07
1346 Section XI • Kyphosis and Postlaminectomy Deformities TABLE 125.1 Algorithm of Preparation for Corrective

1346 Section XI Kyphosis and Postlaminectomy Deformities

Section XI • Kyphosis and Postlaminectomy Deformities TABLE 125.1 Algorithm of Preparation for Corrective c.

TABLE 125.1

Algorithm of Preparation for Corrective c.

1. Fixed kyphotic deformity identified

2. Full-length spine radiographs

a. identify all deformities

b. establish planned correction (Goal: 15° of residual cervicothoracic kyphosis)

3. MRI scan

a. identify degree of spinal cord compression

b. identify intraspinal pathology (rare)

4. Thorough preoperative medical management

a. cardiac ultrasound (detect aortic stenosis)

b. nutritional assessment (identify and correct deficiencies)

c. bone density scan (identify and treat osteoporosis)

d. serum cotinine levels (confirm smoking cessation)

5. Anesthesia consultation

a. selection of experienced anesthesia colleague

b. patient education of planned anesthesia protocol

6. Halo ring application

7. Custom Risser cast application

MRI, magnetic resonance imaging.

Posterior cervical corrective osteotomy is contraindicated when a patient has a thoracolumbar kyphosis that is of greater magnitude than that of the cervical spine. If deformities in the cervical and thoracolumbar spine are similar, it is suggested that the cervical spine be corrected first, so that subsequent sur- gery and the necessary general anesthetic may be more safely obtained. General contraindications include prohibitive car- diac or pulmonary conditions and impaired mental health or psychiatric conditions that would affect the ability to cooperate with postoperative recovery and rehabilitation. Smoking should be considered an absolute contraindication, as most patients with ankylosing spondylitis have some degree of restrictive lung disease, so that optimizing preoperative pulmonary function is essential. In addition, the adverse effect of nicotine on bone and soft tissue healing must be eliminated by absolute smoking cessation.

OPERATIVE TECHNIQUE

PREOPERATIVE PLANNING

All patients must be thoroughly evaluated from a medical standpoint with an emphasis on cardiac and pulmonary status. Aortic stenosis is prevalent in patients with ankylosing spondyli- tis, thus a cardiac ultrasound should be part of the preoperative evaluation. Any patient with a history of smoking must be eval- uated for the presence of nicotine metabolites in the serum or urine to ensure compliance with smoking cessation. The patient’s nutritional status should be evaluated; advanced deformities may affect the ability to swallow solids and lead to malnutrition. Patients with spondyloarthropathies may also experience ileitis or colitis, further affecting their nutritional status. Bone density may be poor in these patients so there exists the potential for problems with fixation and bone heal- ing. When the potential of nutritional deficiency exists, a bone density scan is obtained to identify osteoporosis, which, if pres- ent, should be treated. A preoperative consultation with expe- rienced anesthesia personnel is essential, because of the critical

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TABLE 125.2

Algorithm of Surgical Technique Corrective Cervicothoracic Osteotomy

1. Positioning

a. patient awake and sitting upright

b. halo ring support via rope to overhead pulley

c. custom-fit Risser cast in place

d. arms and legs well padded

2. Surgical exposure

a. infiltration with local anesthetic

b. midline exposure (C5-T2)

c. subperiosteal dissection to tips of lateral masses

d. deep fascial sutures placed initially (prior to osteotomy)

e. spinous process wires placed prior to osteotomy (alternatively:

lateral mass and pedicle screws placed)

3. C7-T1 osteotomy

a. laminectomies of C6, C7, T1

b. complete C7-T1 foraminotomies (C8 root entirely exposed)

c. C7 pedicle and superior aspect of T1 pedicle removed

d. brief general anesthetic during manual correction

e. correction via slow, manual traction on halo ring

f. visual inspection of corrected position

g. application of Luque ring to previously placed wires (alternatively: rods to previously placed screws)

h. general anesthetic reversed and neurologic assessment performed

i. morcelized local bone graft placed

4. Closure

a. via previously placed deep fascial sutures

b. subcutaneous and skin closure

c. halo ring secured to Risser cast

supportive role played by the anesthesiologist during the pro- cedure, much of which is performed with the patient awake. Full-length radiographs of the entire spinal column are obtained to assess the magnitude of the cervicothoracic defor- mity and to determine the presence and magnitude of deformi- ties within the thoracolumbar spine. Magnetic resonance imag- ing (MRI) scans should be routinely obtained to evaluate the degree of spinal cord compression and to detect the unlikely possibility of intraspinal pathology. The chin--brow to vertical angle measures the degree of flex- ion deformity in patients with ankylosing spondylitis and is use- ful to predict the anticipated degree of postoperative correc- tion. The chin--brow to vertical angle is the angle between a line connecting the chin and brow and a vertical line with the patient standing with the hips and knees extended and the neck in the neutral position (Fig. 125.1). In general, the amount of planned correction should leave the patient with 10° to 15° of residual kyphosis. Overcorrection of the kyphosis can leave the patient without the ability for downward gaze. In patients who have severe fixed deformities of both the cervical and tho- racolumbar spines, it is suggested to address the cervical spine first, so that subsequent surgical procedures are not compli- cated by the difficulty of obtaining successful intubation that would occur with a fixed chin-on-chest deformity. Each patient should be fit preoperatively with a halo ring and custom-made Risser cast. A standard halo vest will not ade- quately fit the kyphotic dimensions of a patient’s thoracolum- bar kyphosis, nor will it provide adequate fixation of the torso and pelvis. In addition, it is necessary to conform the posterior aspect of the thoracic cast vest to allow sufficient room for the

the posterior aspect of the thoracic cast vest to allow sufficient room for the 8 8/26/11

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the posterior aspect of the thoracic cast vest to allow sufficient room for the 8 8/26/11
Chapter 125 • Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1347 Figure 125.1. The chin--brow to

Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity

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Extension Osteotomy for Chin-On-Chest Deformity 1347 Figure 125.1. The chin--brow to vertical angle is the angle
Extension Osteotomy for Chin-On-Chest Deformity 1347 Figure 125.1. The chin--brow to vertical angle is the angle

Figure 125.1. The chin--brow to vertical angle is the angle between a line connecting the chin and brow and a vertical line with the patient standing with the hips and knees extended and the neck in the neutral position.

sterile operative field and to provide an adequate abdominal hole to allow for abdominal breathing, as most patients have limited chest expansion and depend greatly on abdominal mechanisms for breathing.

ANESTHESIA

The majority of the procedure is performed with the patient sedated but awake. The patient is lightly premedicated with an infusion of midazolam. Monitoring equipment includes an arterial line, an electrocardiogram (EKG), a noninvasive blood pressure cuff, a pulse oximeter, and a precordial Doppler probe. A nasal airway is placed after a topical anesthetic has been applied to the nares. A clear, light face mask is place to deliver continuous oxygen flow. Short-acting agents such as ket- amine or propofol are administered continuously to allow the patient to remain sedated but conscious and able to follow ver- bal commands. A brief anesthetic is performed at the time of the corrective osteotomy.

POSITIONING

The patient is placed in the sitting position with the head and neck in the upright fashion (Fig. 125.2). The halo ring is secured to an overhead pulley (suspended from the ceiling) with 10 lb. The patient is strapped into the seated position so that there is no sliding forward at the time of the osteotomy. A pillow is placed under the flexed knees and pillows placed under the elbows to allow the arms to rest freely.

SURGICAL TECHNIQUE

A midline approach is made to expose the posterior aspect of the lower cervical and upper thoracic spines. Prior to the skin

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WBK836_Ch125_p1345-1354.indd 1347 1347 Figure 125.2. Lateral view of the patient from Illustrative
WBK836_Ch125_p1345-1354.indd 1347 1347 Figure 125.2. Lateral view of the patient from Illustrative

Figure 125.2. Lateral view of the patient from Illustrative Case 125.1 in the sitting position in the operating room. The arms are comfortably propped on pillows, and the patient is strapped onto the table. The halo ring is suspended directly overhead to a pulley in the ceiling. The operating surgeon stands behind the patient to perform the surgery.

incision, local anesthetic (0.75% bupivacaine [Marcaine] with epinephrine diluted in saline in a 1:2 ratio) is infiltrated in the subcutaneous and paraspinal musculature and down to and including the periosteum of the spinous processes and laminae of C5-T2. A standard subperiosteal dissection is performed to expose from C5-T2, to include the complete lateral extent of the posterior aspect of the spine. A radiograph is obtained to confirm exposure of the appropriate levels. It is helpful to place the deep fascial sutures immediately after the initial surgical exposure has been performed, as the wound becomes mark- edly deformed following the corrective osteotomy and ana- tomic closure of the deep layers is difficult unless those sutures have been placed beforehand. The instrumentation employed for internal fixation should be applied prior to the decompression and corrective osteot- omy. This allows a safer scenario in which the handling and insertion of fixation devices is not performed over the exposed spinal cord. With instrumentation already in place, internal sta- bility can also be expeditiously obtained once the osteotomy has been performed. Spinous process wiring and a Luque rect- angle can be safely and easily employed as instrumentation devices. Sixteen-gauge wires with Drummond buttons are placed through holes drilled in the spinous processes of C6 and T1 or T2. The wires are then tucked under the retractors to allow an open field to perform the subsequent decompression.

A Luque rectangle is selected and prebent to accommodate the

dimensions of the corrected spine following the osteotomy.

Alternatively, lateral mass screw fixation in the cervical spine and pedicle screw fixation in the thoracic spine may be used, although it may not be performed with same the ease an speed

as wiring. C7-T1 is selected as the leel to perform the osteotomy to afford maximal correction through the cervicothoracic junc-

tion. The spinal canal is sufficiently wide at this level, and there

is adequate mobility of the C8 roots to reduce the likelihood of

iatrogenic spinal cord or nerve root injury. Equally important,

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the likelihood of iatrogenic spinal cord or nerve root injury. Equally important, 8 8/26/11 /26/11 5
1348 Section XI • Kyphosis and Postlaminectomy Deformities T1 C6 Removal of spinous processes and

1348 Section XI Kyphosis and Postlaminectomy Deformities

Section XI • Kyphosis and Postlaminectomy Deformities T1 C6 Removal of spinous processes and lamina C6-T1
T1
T1

C6

Removal of spinous processes and lamina C6-T1

Figure 125.3. Illustration of wide surgical exposure and removal of spinous processes at the beginning of the decompression.

the vertebral artery enters the transverse foramina at C6; performing the osteotomy caudal to this level decreases the chance of injury to it during the exposure and correction. A laminectomy is performed at C6, C7, and T1 (Fig. 125.3). A 3-mm high-speed burr is used to create laminectomy troughs to the ventral cortex of each lamina, and the laminectomy is com- pleted with fine, angled microscopic-type Kerrison rongeurs. In this fashion, no excessive pressure is exerted on the contents of the spinal canal. The laminae are then lifted as a unit, taking care to identify any dural adhesions. Bipolar cautery is used to control the epidural venous bleeding that is frequently encountered. Once the laminectomies have been performed, the exiting C8 nerve roots should be completely unroofed so that they can be traced from their origins laterally into the soft tissue. The high-speed burr is used to decorticate the C7-T1 facet joints down to the ventral cortical bone and once again the fine- angled Kerrison rongeur is used to complete the foramino- tomy and expose the exiting C8 roots bilaterally (Figs. 125.4A and B). The foraminotomy must be extended all the way later- ally into the soft tissue so that there is no bone bridge that would limit the completion of the osteotomy or lead to C8 nerve root compression as the osteotomy is closed. The C7 pedicle and the superior aspect of the T1 pedicle are burred away ventrally to the posterior cortex of the vertebral body, to further provide adequate room for the C8 root at the time of the osteotomy and correction. During the nerve root decom- pression, the patient may experience paresthesias in the C8 distribution. This can be remedied by application of cottonoid patties soaked in local anesthetic, although care should be taken to avoid placement of the patties centrally over the the- cal sac, as the anesthetic might directly anesthetize the spinal cord.

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With an adequate central and foraminal decompression performed (and with the instrumentation in place) the osteot- omy is performed (Figs. 125.5 and 125.6). The surgical and anesthesia teams prepare themselves to carry out the osteotomy in a coordinated fashion. The assistant surgeon moves to the front of the patient and grasps the halo ring. A brief general anesthetic is started when the osteotomy is to be performed. The operative surgeon begins slow posterior traction on the halo ring until sufficient correction is obtained. The osteotomy (a closed anterior osteoclasis) occurs at the level of the C7-T1

disc space. As the corrected position is obtained, there is wrin- kling of the dura (Fig. 125.7). As the assistant surgeon holds the head in the corrected position, the primary surgeon walks

to the front of the patient to evaluate the corrected position, by

assessing the alignment of the chin and brow in relation to the patient’s chest. If a preoperative rotary deformity exists in addi- tion to the fixed kyphosis, additional bone may be removed on one side to correct the rotational component. If the position is acceptable, the morcelized local bone graft can be placed in the lateral gutters after the lateral masses and facet joints have been decorticated (Fig. 125.8). The prebent Luque rectangle is then slid down on either side of the spinous process wires, which are then tightened and trimmed (Fig. 125.9). Alternatively,

prebent rods can be secured to the previously placed screws. At the completion of the fixation, the patient is awakened and asked to move all extremities to document that no neurological deficit has occurred. The wound is then closed in layers. A suction drained is placed deep to the fascia. The assistant surgeon has continued to hold the head in the corrected position until the wound is completely closed and a soft dressing placed at which point the halo ring is attached to the custom-molded plaster cast. The patient is monitored in the postanesthesia care unit until fully awake.

POSTOPERATIVE CARE

Patients are mobilized rapidly on the first postoperative day. Drains are generally removed on the second postoperative day.

A liquid diet is begun, as tolerated, on the first or second post-

operative day. Dysphagia may be a problem for some patients,

as the esophagus is tented about the osteotomy site and as the

patient learns to accommodate for the new head position and the restraints of the halo vest. Most patients are able to tolerate

at least a modified solid diet by the time of discharge. Require-

ments for discharge include independent ambulation, ade- quate nutritional status, and use of oral analgesics. The halo vest is employed for 3-months postoperatively. At this point, plain radiographs and a fine-cut computed tomogra- phy (CT) scan with coronal and sagittal reconstructions are obtained to confirm healing of the fusion and osteotomy. If healing is adequate, a hard collar is placed for additional 3 months and if at that time radiographs continue to confirm solid fusion, all immobilization is discontinued.

COMPLICATIONS

The most serious complications are death and paralysis, but these events are fortunately quite rare in most published series. With the exception of a brief period of general anes- thetic during the corrective osteotomy, the patient is sedated,

of general anes- thetic during the corrective osteotomy, the patient is sedated, 8 8/26/11 /26/11 5

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of general anes- thetic during the corrective osteotomy, the patient is sedated, 8 8/26/11 /26/11 5
Chapter 125 • Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1349 Laminectomy C6 Decompressed Bone

Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity

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Laminectomy C6 Decompressed Bone removed c8 n. Laminectomy T1 Removal of C7 pedicle (diamond burr)
Laminectomy C6
Decompressed
Bone removed
c8 n.
Laminectomy T1
Removal of
C7 pedicle
(diamond burr)
A
B

Figure 125.4. (A) Illustration of the completed decompression, with exposure from C6 through T1. The burr is removing the inferior portion of the C7 pedicle. (B) Photograph of the completed decompression; cottonoid patties cover the thoroughly unroofed C8 nerve roots.

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roots. L LWBK836_Ch125_p1345-1354.indd WBK836_Ch125_p1345-1354.indd 1349 1349 8 8/26/11 /26/11 5 5:42:08 :42:08 P PM M

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1350 Section XI • Kyphosis and Postlaminectomy Deformities Head extended manually Figure 125.5. Illustration of

1350 Section XI Kyphosis and Postlaminectomy Deformities

Section XI • Kyphosis and Postlaminectomy Deformities Head extended manually Figure 125.5. Illustration of the
Section XI • Kyphosis and Postlaminectomy Deformities Head extended manually Figure 125.5. Illustration of the
Section XI • Kyphosis and Postlaminectomy Deformities Head extended manually Figure 125.5. Illustration of the

Head extended

manually

Figure 125.5. Illustration of the head position during the osteot- omy; this is controlled by the operative surgeon from posterior and the assistant from anterior.

C7

surgeon from posterior and the assistant from anterior. C 7 C7 T1 Laminectomy C6, C7, T1
C7 T1
C7
T1

Laminectomy C6, C7, T1

Avulsion

fracture

PREOP POSTOP Figure 125.6. Illustrations of the level of the osteotomy and the pre- and
PREOP
POSTOP
Figure 125.6. Illustrations of the level of the osteotomy and the
pre- and postoperative alignment.
Dura
buckles
T2

Figure 125.7. Illustration of the dura buckling as the osteotomy has been completed.

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Bone chips Decompressed C8 n. Gelfoam Figure 125.8. Illustration of the previously placed spinous process
Bone chips
Decompressed
C8 n.
Gelfoam
Figure 125.8. Illustration of the previously placed spinous process
wires in position and bone graft being placed laterally. Gelfoam
covers the dura.
Luque
rectangle
Figure 125.9. The Luque rectangle has been placed and the wires
tightened.
Figure 125.9. The Luque rectangle has been placed and the wires tightened. 8 8/26/11 /26/11 5

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Chapter 125 • Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1351 but awake and able to

Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity

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Extension Osteotomy for Chin-On-Chest Deformity 1351 but awake and able to respond to verbal stimulation from

but awake and able to respond to verbal stimulation from the anesthesiologist. In the event of cardiac or respiratory deterio- ration, intervention can be immediate. Spinal cord monitor- ing is generally not performed as a patient’s direct response is obtained by verbal questioning from the anesthesiologist. With the patient awake, adverse neurological events should be immediately detected and surgical alterations can be made promptly. With dramatic correction in patients with longstanding chin-on-chest deformity, the anterior cervical musculature may become tight following correction. This causes stress on the instrumentation and loss of correction may occur. Instances of devastating neurological consequences from loss of correction and ensuing spinal cord compression have been described. However, with the use of both internal fixation and halo vest immobilization typically the correction will not be disrupted. In the event that tight anterior musculature threat- ens to disrupt the osteotomy or is causing severe dysphagia, surgical tenotomies of the sternocleidomastoid muscles may be indicated. Late loss of correction or pseudarthrosis at either the osteot- omy site or posterolateral fusion is also uncommon if rigid internal fixation and adequate post-operative immobilization are employed. Careful radiographic surveillance is essential to document maintenance of correction and appropriate boney healing. C8 nerve root palsy may occur if an adequate decompres- sion is not performed, underscoring the importance of com- plete C7-T1 foraminotomy and partial pedicle resection of each level prior to the corrective osteotomy. The C8 roots must be carefully inspected after closure of the osteotomy to ensure that no nerve compression exists. A mild C8 palsy may nonethe-

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less occur in some cases. These generally resolve over time with supportive treatment alone.

CONCLUSION

The profound disability that occurs with a fixed chin-on-chest deformity can be addressed with a posterior cervicothoracic extension osteotomy. Careful preoperative planning and atten- tion to detail with surgical technique help to ensure a successful outcome. Patients with equally severe cervicothoracic and thora-

columbar deformities should have the cervical osteotomy per- formed first as this will allow for safe endotracheal intubation for subsequent surgeries. An experienced anesthesiologist who is actively involved prior to surgery and with whom open communi- cation is maintained during surgery is of paramount importance.

A well-molded plaster vest should be fit individually for each

patient preoperatively, conforming to his or her unique spinal dimensions and allowing for an adequate surgical field. The

C7-T1 level is the typical level for the osteotomy. A wide decom- pression is essential, and special attention is paid to the C8 nerve roots to avoid postoperative palsy. Internal fixation should be placed prior to the decompression to allow for safe and expedient internal stabilization once the osteotomy is performed. Choice of fixation device is based on surgeon preference, although spinous process wires with Drummond buttons secured to a Luque rect- angle has a proven track record clinically and is safe and easily placed. The osteotomy itself is directly performed and inspected

by the primary surgeon, with care to maintain 10° to 15° of resid-

ual kyphosis to avoid overcorrection. Careful clinical and radio- graphic surveillance postoperatively is critical to confirm the maintenance of correction and appropriate boney healing.

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critical to confirm the maintenance of correction and appropriate boney healing. 8 8/26/11 /26/11 5 5:42:11
1352 Section XI • Kyphosis and Postlaminectomy Deformities ILLUSTRATIVE CASE 125.1 A 38-year-old man with

1352 Section XI Kyphosis and Postlaminectomy Deformities

ILLUSTRATIVE CASE 125.1

and Postlaminectomy Deformities ILLUSTRATIVE CASE 125.1 A 38-year-old man with ankylosing spondylitis presented with

A 38-year-old man with ankylosing spondylitis presented with severe neck pain, inability to look forward, and great difficulty with hygiene and swallowing (Figs. 125.10A and B). A lateral radiograph revealed fixed cervicothoracic

kyphosis (Fig. 125.10C). He underwent a posterior correc- tive osteotomy with dramatic improvement clinically (Fig. 125.11A) and radiographically (Figs. 125.11B and C).

A C
A
C
B
B

Figure 125.10. (A to C) Preoperative photographs and lateral radiograph of Case 125.1.

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Chapter 125 • Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1353 A B C Figure 125.11.

Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity

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A B
A
B
C
C

Figure 125.11. (A to C) Postoperative lateral photograph and radiograph of Case 125.1 revealing excellent clinical correction of alignment and radiographic healing of osteotomy.

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osteotomy. L LWBK836_Ch125_p1345-1354.indd WBK836_Ch125_p1345-1354.indd 1353 1353 8 8/26/11 /26/11 5 5:42:14 :42:14 P PM M

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1354 Section XI • Kyphosis and Postlaminectomy Deformities ILLUSTRATIVE CASE 125.2 A 47-year-old man with

1354 Section XI Kyphosis and Postlaminectomy Deformities

ILLUSTRATIVE CASE 125.2

and Postlaminectomy Deformities ILLUSTRATIVE CASE 125.2 A 47-year-old man with previously undiagnosed ankylosing

A 47-year-old man with previously undiagnosed ankylosing

spondylitis presented with a fixed chin-on-chest deformity,

severe neck pain, and both subjective and objective evidence

of myelopathy (Fig. 125.12). A posterior cervicothoracic

extension osteotomy was performed with halo vest immobi- lization. At 10-year follow-up, his correction was maintained clinically and he remained employed as a laborer (Fig. 125.13).

and he remained employed as a laborer (Fig. 125.13). Figure 125.12. Preoperative photograph of Case 125.2

Figure 125.12. Preoperative photograph of Case 125.2 revealing deformity and patient wearing custom-made plaster body cast.

RECOMMENDED READINGS

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LLWBK836_Ch125_p1345-1354.inddWBK836_Ch125_p1345-1354.indd

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Figure 125.13. Postoperative photograph of Case 125.2 revealing maintenance of corrected alignment at 10-year follow-up.

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