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Christopher P. Ames, Justin S. Smith, Robert Eastlack, Donald J. Blaskiewicz, Christopher I. Shaffrey, Frank Schwab, Shay Bess, Han Jo Kim, Gregory M. Mundis Jr., Eric Klineberg, Munish Gupta, Michael O’Brien, Richard Hostin, Justin K. Scheer, Themistocles S. Protopsaltis, Kai-Ming G. Fu, Robert Hart, Todd J. Albert, K. Daniel Riew, Michael G. Fehlings, Vedat Deviren, Virginie Lafage, and International Spine Study Group

D espite the complexity of cervical spine deformity (CSD) and its substantial impact on patient quality of life, there exists no comprehensive classification system to serve as the basis of communication among physicians and to facilitate effective clinical and radiographic study of patients with these deformities. Without a standardized classification system, studies of CSD may suffer from heterogeneity, which compromises the study findings and negatively impacts communication of the results. Other spinal conditions, including adult and pediatric

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Andrei F. Joaquim and K. Daniel Riew

P osterior cervical approaches for the treatment of intradural spinal lesions, such as intramedullary or extramedullary tumors, require posterior decompressive techniques. Cervical spine deformity secondary to sagittal and/or coronal imbalance after a laminectomy may result in important cervical pain and functional deterioration, along with neurological deficits in the most severe cases. 2 , 10 , 21 In general, the majority of deformities secondary to cervical laminectomy occur in the sagittal plane, resulting in cervical kyphosis. 9 , 14 Many risk

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Daniel R. Fassett, Randy Clark, Douglas L. Brockmeyer, and Meic H. Schmidt

✓ Postoperative sagittal-plane cervical spine deformities are a concern when laminectomy is performed for tumor resection in the spinal cord. These deformities appear to occur more commonly after resection of intramedullary spinal cord lesions, compared with laminectomy for stenosis caused by degenerative spinal conditions. Postlaminectomy deformities are most common in pediatric patients with an immature skeletal system, but are also more common in young adults (< 25 years of age) in comparison with older adults. The extent of laminectomy and facetectomy, number of laminae removed, location of laminectomy, preoperative loss of lordosis, and postoperative radiation therapy in the spine have all been reported to influence the risk of postlaminectomy spinal deformities. When these occur, patients should be monitored closely with serial imaging studies, because a significant percentage will have progressive deformities. These can range from focal kyphosis to more complicated swan-neck deformities. General indications for surgical intervention include progressive deformity, axial pain in the area, and neurological symptoms attributable to the deformity. Surgical options include anterior, posterior, and combined anterior–posterior procedures. The authors have reviewed the literature on postlaminectomy kyphosis as it relates to resection of cervical spinal cord tumors, and they summarize some general factors to consider when treating these patients.

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Nobuhito Morota, Satoshi Ihara, Hideki Ogiwara, and Goichiro Tamura

based on characteristic dwarfism, facial anomalies, and other clinical features. Fig. 1. Case 8. Sagittal CT reconstruction obtained in a child with CPD and cervical spine deformity showing aberrant punctiform deposition of calcium called stippled epiphyses in the cervical spine ( arrows ). Because of the rare occurrence of CDP and differences in pathogenesis between the subtypes, the involvement of the central nervous system in this disease group is not fully understood. Associated cervical spine stenosis and deformity, including atlantoaxial dislocation (AAD) at the

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Arnold B. Etame, Anthony C. Wang, Khoi D. Than, Frank La Marca, and Paul Park

In patients with severe fixed cervicothoracic kyphosis, the significant compromise of horizontal gaze served as the basis for surgical intervention. 3 , 14 , 16 , 23 , 28 Radiographic assessments were used to ascertain the extent of deformity, possible stenosis, and the degree of correction necessary. These studies usually entailed MR imaging, CT scanning, and static and dynamic plain radiographs of the cervical spine. Surgical Technique Techniques for correction of cervical spine deformity were quite varied and depended on pathology. In patients with

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Nikita G. Alexiades, Belinda Shao, Bruno P. Braga, Christopher M. Bonfield, Douglas L. Brockmeyer, Samuel R. Browd, Michael DiLuna, Mari L. Groves, Todd C. Hankinson, Andrew Jea, Jeffrey R. Leonard, Sean M. Lew, David D. Limbrick Jr., Francesco T. Mangano, Jonathan Martin, Joshua Pahys, Alexander Powers, Mark R. Proctor, Luis Rodriguez, Curtis Rozzelle, Phillip B. Storm, and Richard C. E. Anderson

T raction is an invaluable tool for the management of both cervical spine trauma and cervical spine deformity. The use of traction to achieve closed reduction, for example, is widely used in traumatic facet dislocations and odontoid fractures. 1–4 Furthermore, halo-gravity traction (HGT) has demonstrated benefit in the management of spinal deformity including basilar invagination, irreducible atlantoaxial rotatory subluxation, cervical kyphosis, and os odontoideum. 5–9 The overwhelming majority of existing literature that guides clinical practice is

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Justin S. Smith, Thomas J. Buell, Christopher I. Shaffrey, Han Jo Kim, Eric Klineberg, Themistocles Protopsaltis, Peter Passias, Gregory M. Mundis Jr., Robert Eastlack, Vedat Deviren, Michael P. Kelly, Alan H. Daniels, Jeffrey L. Gum, Alex Soroceanu, Munish Gupta, Doug Burton, Richard Hostin, Robert Hart, Virginie Lafage, Renaud Lafage, Frank J. Schwab, Shay Bess, and Christopher P. Ames

A dult cervical spine deformity (ACSD) can have profound impact on quality of life, including pain, disability, and neurological compromise. A recent report assessed the health status of symptomatic ACSD patients presenting for surgical treatment based on the EQ-5D questionnaire. 1 ACSD patients had a mean EQ-5D index that was 34% below the bottom 25th percentile for an age- and sex-matched normative United States population. This negative health impact was evident across all domains of the EQ-5D and was not significantly different based on deformity type. The

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Christopher P. Ames, Justin S. Smith, Justin K. Scheer, Christopher I. Shaffrey, Virginie Lafage, Vedat Deviren, Bertrand Moal, Themistocles Protopsaltis, Praveen V. Mummaneni, Gregory M. Mundis Jr., Richard Hostin, Eric Klineberg, Douglas C. Burton, Robert Hart, Shay Bess, Frank J. Schwab, and the International Spine Study Group

Deviren V , Scheer JK , Ames CP : Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases. Clinical article . J Neurosurg Spine 15 : 174 – 181 , 2011 10 Etame AB , Than KD , Wang AC , La Marca F , Park P : Surgical management of symptomatic cervical or cervicothoracic kyphosis due to ankylosing spondylitis . Spine (Phila Pa 1976) 33 : E559 – E564 , 2008 11 Etame AB , Wang AC , Than KD , La Marca F , Park P : Outcomes after surgery for cervical spine

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Bram P. Verhofste, Michael P. Glotzbecker, Craig M. Birch, Nora P. O’Neill, and Daniel J. Hedequist

OBJECTIVE

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities.

METHODS

Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2–24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications.

RESULTS

The mean duration of HGT was 25 days (IQR 13–29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%–40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°–122°) to 56° ± 17.6° (range 32°–96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%–57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17–43 days).

Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24–48 hours.

CONCLUSIONS

HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

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Kyle M. Fargen, Richard C. E. Anderson, David H. Harter, Peter D. Angevine, Valerie C. Coon, Douglas L. Brockmeyer, and David W. Pincus

Object

Although rarely encountered, pediatric patients with severe cervical spine deformities and instability may occasionally require occipitocervicothoracic instrumentation and fusion. This case series reports the experience of 4 pediatric centers in managing this condition. Occipitocervical fixation is the treatment of choice for craniocervical instability that is symptomatic or threatens neurological function. In children, the most common distal fixation level with modern techniques is C-2. Treated patients maintain a significant amount of neck motion due to the flexibility of the subaxial cervical spine. Distal fixation to the thoracic spine has been reported in adult case series. This procedure is to be avoided due to the morbidity of complete loss of head and neck motion. Unfortunately, in rare cases, the pathological condition or highly aberrant anatomy may require occipitocervical constructs to include the thoracic spine.

Methods

The authors identified 13 patients who underwent occipitocervicothoracic fixation. Demographic, radiological, and clinical data were gathered through retrospective review of patient records from 4 institutions.

Results

Patients ranged from 1 to 14 years of age. There were 7 girls and 6 boys. Diagnoses included Klippel-Feil, Larsen, Morquio, and VATER syndromes as well as postlaminectomy kyphosis and severe skeletal dysplasia. Four patients were neurologically intact and 9 had myelopathy. Five children were treated with preoperative traction prior to instrumentation; 5 underwent both anterior and posterior spinal reconstruction. Two patients underwent instrumentation beyond the thoracic spine. Allograft was used anteriorly, and autologous rib grafts were used in the majority for posterior arthrodesis. Follow-up ranged from 0 to 43 months. Computed tomography confirmed fusion in 9 patients; the remaining patients were lost to follow-up or had not undergone repeat imaging at the time of writing. Patients with myelopathy either improved or stabilized. One child had mild postoperative unilateral upper-extremity weakness, and a second child died due to a tracheostomy infection. All patients had severe movement restriction as expected.

Conclusions

Occipitocervicothoracic stabilization may be employed to stabilize and reconstruct complex pediatric spinal deformities. Neurological function can be maintained or improved. The long-term morbidity of loss of cervical motion remains to be elucidated.