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cervical_spine_deformity

Cervical spine deformity

Epidemiology

High prevalence of residual cervical deformity CD has been identified after surgical treatment of adult spinal deformity. Development of new onset CD is less understood and its clinical impact unclear.

A total of 47.7% of patients without preoperative CD developed new onset postoperative CD after thoracolumbar surgery. Independent predictors of new onset CD at 2 years included diabetes, higher preoperative T1 slope minus cervical lordosis, and ending instrumentation above T4. Significant improvements in health-related quality of life scores occurred despite the development of postoperative CD 1).

Classification

see Cervical kyphotic deformity.

Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system.

Ames et al. proposed a classification that provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification 2).

Etiology

Cervical deformities arise from a multitude of causes, including genetic, congenital, inflammatory, degenerative, and iatrogenic etiologies.

Although congenital and hereditary causes of cervical deformity require specialized attention to particular clinical features and operative considerations, postsurgical (iatrogenic) cervical deformity after surgery is the most common single cause.

The neck is extremely flexible. This flexibility often puts the neck at risk for injury. Some injuries (such as a dislocation or fracture) can create a spinal deformity within the cervical canal.

A deformity of the spine in the cervical region shows itself as an abnormal curve or angulation in the normally smoothly curved neck. The cause is degenerative facet or disc disease at multiple levels.

The normal neck alignment in the front to back view should be straight up and down and from the side, should display a backwards curve called a lordosis. The lordosis is caused by the trapezoidal shape of the discs. The bodies of the vertebra are square and stacking them up on top of each other without the discs and facets would form a straight tower.

If the discs or facets break down (and they normally do), but break down asymmetrically, an abnormal alignment occurs. If this breakdown occurs at only one level, the malalignment rarely causes an abnormal curve. If this breakdown occurs at multiple levels, a deformity of the spine will result. One level's abnormal angulation will add to the abnormal angulation above and below to cause a scoliosis or a cervical kyphotic deformity.

Clinical features

Cervical spine deformities can have a significant negative impact on the quality of life by causing pain, myelopathy, radiculopathy, sensorimotor deficits, as well as inability to maintain horizontal gaze in severe cases 3).

A deformity of the spine that may cause a curvature of the neck often causes the head to be held in an unusual posture when the neck is in a “relaxed” position. Muscle contraction is needed to hold the head in a normal position with chin neutral and eyes level. Chronic muscle contraction causes a dull crampy type of neck pain that is relieved with lying down.

Pain from neck deformities such as cervical kyphosis, as well as from degenerative conditions, can occur in each segment. That is-a bad disc or facet can cause nerve compression, disc pain, instability, degenerative spondylolysthesis as well as central stenosis and myelopathy (see each section for description of that disorder).

Treatment

Surgical

There are many spine surgeries available today; surgical treatment depends upon the size of the cervical deformity present and what the underlying cause of neck pain is. It may be that the deformity by itself is not causing pain and it is a simple matter to fix a herniated disc or bone spurs compressing a nerve root. If deformity surgery is necessary, the surgery may be performed strictly from the front (an ADCF), from the back (a posterior fusion) or from both sides (a 360).

Flexible deformities can be managed with single-staged procedures, whereas fixed deformities require two-staged or even three-staged procedures. Staged surgery for fixed cervical deformities can achieve up to 28 degrees of angular correction and 31% translational correction 4).

They often require surgical intervention for treatment of pain, progressive structural decompensation, and neurologic deterioration.

Appropriate treatment involves careful selection of conservative and aggressive measures and familiarity with advanced surgical techniques that allow for the safe correction of these challenging deformities.

Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and is often controversial 5) 6).

Non-surgical

Standard conservative treatment for a cervical deformity includes physical therapy, Chiropractic treatment, medications, home traction, massage and injections when necessary.

1)
Passias PG, Soroceanu A, Smith J, Boniello A, Yang S, Scheer JK, Schwab F, Shaffrey C, Kim HJ, Protopsaltis T, Mundis G, Gupta M, Klineberg E, Lafage V, Ames C; International Spine Study Group. Postoperative Cervical Deformity in 215 Thoracolumbar Patients With Adult Spinal Deformity: Prevalence, Risk Factors, and Impact on Patient-Reported Outcome and Satisfaction at 2-Year Follow-up. Spine (Phila Pa 1976). 2015 Mar 1;40(5):283-291. PubMed PMID: 25901975.
2)
Ames CP, Smith JS, Eastlack R, Blaskiewicz DJ, Shaffrey CI, Schwab F, Bess S, Kim HJ, Mundis GM Jr, Klineberg E, Gupta M, O'Brien M, Hostin R, Scheer JK, Protopsaltis TS, Fu KM, Hart R, Albert TJ, Riew KD, Fehlings MG, Deviren V, Lafage V; International Spine Study Group. Reliability assessment of a novel cervical spine deformity classification system. J Neurosurg Spine. 2015 Dec;23(6):673-83. doi: 10.3171/2014.12.SPINE14780. Epub 2015 Aug 14. PubMed PMID: 26273762.
3)
Tan LA, Riew KD, Traynelis VC. Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification. Neurosurgery. 2017 Aug 1;81(2):197-203. doi: 10.1093/neuros/nyx249. PubMed PMID: 28838143.
4)
Chi JH, Tay B, Stahl D, Lee R. Complex deformities of the cervical spine. Neurosurg Clin N Am. 2007 Apr;18(2):295-304. Review. PubMed PMID: 17556131.
5)
Tan LA, Riew KD, Traynelis VC. Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification. Neurosurgery. 2017 Aug 1;81(2):197-203. doi: 10.1093/neuros/nyx249. PubMed PMID: 28838143.
6)
Tan LA, Riew KD, Traynelis VC. Cervical Spine Deformity-Part 2: Management Algorithm and Anterior Techniques. Neurosurgery. 2017 Oct 1;81(4):561-567. doi: 10.1093/neuros/nyx388. PubMed PMID: 28934448.
cervical_spine_deformity.txt · Last modified: 2017/09/27 12:15 by administrador