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Open access

Multiple three-column osteotomies successfully correcting cervicothoracic kyphosis in the setting of ankylosing spondylitis: illustrative case

Luke Mugge, Paul Gorka, Cristie Brewer, and Brian McHugh

BACKGROUND

Ankylosing spondylitis (AS) is an autoimmune spondylarthritis often associated with rigid kyphoscoliosis. The authors describe a surgical approach that employs multilevel three-column osteotomies for the restoration of normal global alignment.

OBSERVATIONS

A 48-year-old male with a past medical history of AS presented to the clinic with a stooped-over posture: his chin-brow vertical angle (CBVA) was 58.0°; T1 slope (T1S), 97.8°; thoracic kyphosis (TK; T1–12), 94.2°; proximal TK (T1–5), 50.8°; distal TK (T5–12), 43.5°; and sagittal vertical axis (SVA), 22.6 cm. A two-stage procedure was planned. During stage 1, instrumentation was placed from C5 to T10, followed by a T3 vertebral column resection. During stage 2, bilateral pedicle screws were placed from T11 to the pelvis. An L3 pedicle subtraction osteotomy (PSO) was completed and was followed by a T7 PSO. Postoperatively, the patient had significant postural improvement: CBVA was 29.3°; T1S, 57.8°; TK, 77.3°; proximal TK, 33.5°; distal TK, 43.8°; and SVA, 15 cm. At 6 years postoperatively, the patient continued to do well and was without evidence of construct breakdown.

LESSONS

The authors propose that multilevel three-column osteotomies, if optimally located, successfully correct spinal malalignment associated with AS.

Open access

Two-year results of single-level fixation with lateral mass screws for cervical degenerative spondylolisthesis: patient series

Hiroyasu Kodama, Naohiro Kawamura, Junichi Ohya, Yuki Onishi, Chiaki Horii, Mitsuhiro Nishizawa, Masaya Sekimizu, Yuji Ishino, and Junichi Kunogi

BACKGROUND

In surgery for cervical spondylotic myelopathy (CSM) with spondylolisthesis, there is no consensus on the correction and fixation for spondylolisthesis. The authors retrospectively studied whether the correction of single-level fixation with lateral mass screws (LMSs) could be maintained.

OBSERVATIONS

The records of patients with CSM with spondylolisthesis who had been treated with posterior decompression and single-level fusion with LMSs from 2017 to 2021 were retrospectively reviewed. Radiographic measurements included cervical parameters such as C2–7 lordosis, T1 slope, and the degree of spondylolisthesis (percent slippage) before surgery, immediately after surgery, and at the final observation.

Ten cases (mean age 72.8 ± 7.8 years) were included in the final analysis, and four cases (40%) were on hemodialysis. The median observation period was 26.5 months (interquartile range, 12–35.75). The mean percent slippage was 16.8% ± 4.7% before surgery, 5.3% ± 4.0% immediately after surgery, and 6.5% ± 4.7% at the final observation. Spearman’s rank correlation showed a moderate correlation between preoperative slippage magnitude and correction loss (r = 0.659; p = 0.038). Other parameters showed no correlation with correction loss.

LESSONS

For CSM with spondylolisthesis, single-level fixation with LMSs achieved and maintained successful correction in the 2-year observation.

Open access

Delayed myelopathy after remote C1–2 sublaminar wire fixation: illustrative case

Aaron Miller, David A. Paul, Prasanth Romiyo, and Jonathan J. Stone

BACKGROUND

Atlantoaxial sublaminar wiring complications, both early and delayed, have been documented. However, delayed neurological compromise 27 years after successful fusion is a rare but possible occurrence.

OBSERVATIONS

A 76-year-old male, who had undergone C1–2 sublaminar wire fusion for atlantoaxial instability in 1995, presented with symptoms of progressive right arm weakness, falls, and incontinence of bowel and bladder over a 1-week period. Initial imaging workup revealed bowing of the C1–2 sublaminar wires resulting in cervical spinal cord compression and T2-weighted signal changes. A C1–2 laminectomy was performed to remove the wires and decompress the spinal cord with improvement in the patient’s neurological status.

LESSONS

This rare case highlights the potential for delayed cervical myelopathy and cord compression from sublaminar wires, even after a successful fusion. In patients with a history of sublaminar wiring who experience new neurological deficits, it is essential to evaluate the hardware for migration.

Open access

Hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome: illustrative case

Shigeyoshi Shimura, Ryu Saito, Takashi Yagi, Hideyuki Yoshioka, and Hiroyuki Kinouchi

BACKGROUND

Intraspinal juxta-facet cysts of the spine are known to predominate at the lumbar level and is relatively rare at the cervical level. Most cervical spinal lesions are found incidentally, but they sometimes cause myelopathy or radiculopathy in a chronic course.

OBSERVATIONS

The authors present a rare case of hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome. An 86-year-old woman presented with acute-onset right hemiparesis following neck pain and was admitted to the local hospital. She was started on antithrombotic therapy with a suspected diagnosis of cerebral infarction, but quadriplegia progressed 2 days later. Cervical magnetic resonance imaging revealed an intraspinal mass at the C4–5 level and she was referred to the authors’ hospital. Her neurological findings on admission revealed right Brown-Séquard syndrome. In emergency surgery, the mass was resected with a posterior approach. Pathological findings showed hemosiderin deposition and fibroblast proliferation, consistent with a juxta-facet cyst with intracystic hemorrhage. The patient recovered well and returned to an independent daily life.

LESSONS

Rarely, juxta-facet cyst of the cervical spine can cause acute Brown-Séquard syndrome due to intraspinal hemorrhage. In a case of hemiparesis that develops following neck pain, hemorrhagic cervical juxta-facet cyst should be taken into consideration as a differentiation.

Open access

Bow hunter’s syndrome: temporary obstruction of blood flow in the affected vertebral artery during posterior occipitocervical fusion. Illustrative case

Takeru Yokota, Koji Otani, Junichi Handa, Takuya Nikaido, Takao Kojima, Naoki Sato, and Shinichi Konno

BACKGROUND

Bow hunter’s syndrome (BHS) is a rare condition characterized by mechanical impingement of a vertebral artery (VA) during neck rotation followed by vertebrobasilar insufficiency. Posterior fusion is a typical surgical method for BHS.

OBSERVATIONS

The case of a 70-year-old Japanese man who presented with presyncope that occurred during right cervical rotation is reported. Given the possibility of vertebrobasilar insufficiency, digital subtraction angiography and computed tomography angiography were performed and showed a hypoplastic right VA and severe stenosis of the left VA over the occiput (O)–C2 level. The blood flow of the left VA was interrupted by right cervical rotation, with resumption of blood flow on left cervical rotation. BHS was diagnosed, and posterior fusion at the O–C2 level was performed. Immediately after implant fixation, selective arteriography confirmed disruption of blood flow in the left VA. The rods were removed immediately; resumption of blood flow was confirmed; and the rods were refixed, anatomically bent with slight left cervical rotation. Then, sustained blood flow in the left VA was confirmed.

LESSONS

Posterior fixation for BHS can induce VA occlusion due to minor changes in cervical spine alignment. Intraoperative selective arteriography is a necessary tool to identify occlusion of the affected VA.

Open access

Coexisting ossification of the posterior longitudinal ligament, intramedullary hemangioblastoma, and syringomyelia of the cervical spine: illustrative case

Chi-Ruei Li, Cheng-Ying Lee, Wen-Yu Cheng, Hsin-Ni Li, Chih-Hsiang Liao, and Chiung-Chyi Shen

BACKGROUND

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of severe spinal cord compression and degenerative cervical myelopathy. Because OPLL is rarely accompanied by prominent syringomyelia, when both are observed, other causes of syringomyelia should be considered. Simultaneous presentation of OPLL and hemangioblastoma of the cervical spine is a rare encounter and has never been reported in the English-language literature.

OBSERVATIONS

The authors present a case of a 64-year-old man with muscle weakness of the right upper limb and worsening dysesthesia of the right thumb and index finger. Noncontrast magnetic resonance imaging (MRI) of the cervical spine from another institution revealed OPLL from the C2 to C6 levels with severe spinal cord compression and prominent syringomyelia. Repeated MRI with contrast showed an intramedullary tumor, about 11 mm in diameter, at the right posterior aspect of the C4 level. The authors performed laminectomies from C1 to C6 with posterolateral fusion and removed the C4 tumor. Pathohistological examination of the tumor demonstrated hemangioblastoma.

LESSONS

Careful evaluation of the preoperative imaging study is extremely important in surgical decision making. Although rare, concomitant cervical hemangioblastoma should be listed in the differential diagnosis when OPLL is accompanied with prominent syringomyelia.

Open access

Recovery from hemidiaphragmatic paralysis with improved respiratory function following cervical laminoplasty and foraminotomy: illustrative case

Kazushi Kitamura, Hideki Hayashi, Ryota Ishibashi, and Hiroki Toda

BACKGROUND

Hemidiaphragmatic paralysis can occasionally be caused by cervical canal and foraminal stenosis. Rarely is the effect of surgical decompression on hemidiaphragmatic paralyzed patient respiratory function recorded. This report details a case of postoperative respiratory function restoration in a patient with cervical spondylosis–related hemidiaphragmatic paralysis.

OBSERVATIONS

A 77-year-old woman suffered hemidiaphragmatic paralysis caused by cervical canal and foraminal stenosis. The phrenic nerve palsy was thought to be caused by compression of the cervical spinal cord and its nerve root. The patient received a C3 laminectomy, a C4–6 laminoplasty, and a left C3–4 and C4–5 posterior foraminotomy. After surgery, she improved her maximum inspiratory pressure and respiratory function.

LESSONS

Cervical canal and foraminal stenosis may cause hemidiaphragmatic paralysis due to radiculopathy-induced phrenic nerve palsy. Laminoplasty and posterior foraminotomy can restore respiratory dysfunction related to diaphragmatic paralysis by decompressing the ventral horn of the spinal cord and spinal nerve root.

Open access

Systemic sclerosis-associated compressive cervical calcinosis: intersection of degenerative spine instability, lesional spinal cord compression, and traumatic spinal cord injury. Illustrative case

Thu Lan Pham, Jingya Miao, Harminder Singh, Marco B. Lee, and Tene A. Cage

BACKGROUND

Tumoral calcinosis, mass-like calcium deposition into the soft tissues, is an uncommon manifestation of the systemic sclerosis subtype of scleroderma. When this process affects the spinal epidural space, it can cause canal narrowing and place the spinal cord at significant risk of injury.

OBSERVATIONS

Here a 62-year-old female with systemic sclerosis and no previous evidence of spinal cord compromise who developed acute spinal cord injury and quadriparesis after a mechanical fall is described. She was found to have a large dorsal epidural calcified mass compressing her cervical spinal cord. She underwent medical management for acute spinal cord compression as well as surgical management for acute spinal cord injury and degenerative spine disease. Her case illustrates a rare etiology of simultaneous degenerative spine instability and lesional spinal cord compression with acute spinal cord injury.

LESSONS

Tumor calcinosis leading to acute spinal cord injury in the setting of systemic sclerosis is an uncommon but critical entity to recognize in patients with scleroderma and may require the physician to use a combination of medical and surgical management strategies from each of these categories of spine pathology.

Open access

Catastrophic delayed cervical arthroplasty failure: illustrative case

Diego A. Carrera and Christian B. Ricks

BACKGROUND

Cervical disc replacement (CDR) is an increasingly used alternative to fusion for symptomatic cervical disc disease. While more studies have suggested favorability of CDR over fusion procedures, limited data exist regarding implant fatigability. Here, the authors present a unique and previously unreported failure of the M6-C prosthesis causing spinal cord injury.

OBSERVATIONS

A 49-year-old female with history of cervical degenerative disease and prior C4–7 M6-C arthroplasty presented 9 years later after a minor fall from standing. She endorsed bilateral hand numbness ascending to forearms and shoulders, with dysesthesias and weakness. Imaging showed fractured arthroplasty penetrating the spinal cord. Revision surgery found a ruptured arthroplasty annulus with metal piece piercing the spinal cord. Partial C4 and C5 corpectomy was performed to remove the integrated fins of the arthroplasty and inspect the cord and dura. This was reconstructed with a corpectomy cage and plate. The patient made an excellent recovery, with improvement in her weakness and resolution of her sensory symptoms.

LESSONS

Possibility of fatigue-related failures presenting years after implantation have only been infrequently reported but can be catastrophic for patients. The authors encourage further discussions in this area, increased counseling with patients, and recommend a patient registry to better document adverse events.

Open access

Occipitocervical fusion of traumatic atlanto-occipital dissociation in a patient with autofused cervical facet joints: illustrative case

J. Manuel Sarmiento, Daniel Chang, Peyton L. Nisson, Julie L. Chan, and Tiffany G. Perry

BACKGROUND

Patients who survive traumatic atlanto-occipital dissociation (AOD) may present with normal neurological examinations and near-normal-appearing diagnostic images, such as cervical radiographs and computed tomography (CT) scans.

OBSERVATIONS

The authors described a neurologically intact 64-year-old female patient with a degenerative autofusion of her right C4–5 facet joints who presented to their center after a motor vehicle collision. Prevertebral soft tissue swelling and craniocervical subarachnoid hemorrhage prompted awareness and consideration for traumatic AOD. An abnormal occipital condyle–C1 interval (4.67 mm) on CT and craniocervical junction ligamentous injury on magnetic resonance imaging (MRI) confirmed the diagnosis of AOD. Her autofused right C4–5 facet joints were incorporated into the occipitocervical fusion construct.

LESSONS

Traumatic AOD can be easily overlooked in patients with a normal neurological examination and no associated upper cervical spine fractures. A high index of suspicion is needed when evaluating CT scans because normal values for craniocervical parameters are significantly different from the accepted ranges of normal on radiographs in the adult population. MRI of the cervical spine is helpful to evaluate for atlanto-occipital ligamentous injury and confirm the diagnosis. Occipitocervical fusion construct may need to be extended to incorporate spinal levels with degenerative autofusion to prevent adjacent level degeneration.