Anaesthesia for posterior cervical osteotomy

Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes

STUDY DESIGN

A retrospective review of the cervical extension osteotomy in the past 36 years for the treatment of flexion deformity of patients with ankylosing spondylitis was conducted.

OBJECTIVES

To review the conventional and current surgical techniques of cervical extension osteotomy in ankylosing spondylitis and to evaluate the clinical outcomes.

SUMMARY OF BACKGROUND DATA

Cervical osteotomy is a challenging procedure in the correction of flexion deformity in ankylosing spondylitis. Some authors prefer using general anesthesia and prone position for their surgery, and some, including the authors, use the sitting position.

METHODS

A review of 131 cases of cervical spine osteotomy was carried out. The accumulation of 131 cases was classified into two phases: 114 cases from 1967 to 1997 (conventional technique group) by our senior author and 17 cases from 1997 to 2003 (current technique group) by our first author. Patient follow-up was obtained by a combination of retrospective chart review and telephone interview by 2 independent physicians. The flexion deformity was measured before surgery and after surgery using chin-brow to vertical angle.

RESULTS

There were 114 patients in the conventional group and 17 patients in the current group. The average preoperative and postoperative angle was 56 degrees and 4 degrees , respectively, in the conventional group and 49 degrees and 12 degrees , respectively, in the current group.

CONCLUSIONS

The sitting position with local anesthesia is safe and allows for correction of deformity in a controlled manner. The increased lateral resection area reduces the possibility of nerve root impingement and provides ample room for the spinal cord. The cranial halo can also be adjusted after surgery to modify the head/neck position and can be adjusted to alleviate any C8 nerve root impingement. The procedure demands great attention to detail to minimize risk.

New approach to cervical flexion deformity in ankylosing spondylitis. Case report

The treatment of cervical fixed flexion deformity in ankylosing spondylitis presents a challenging problem that is traditionally managed by a corrective cervicothoracic osteotomy. The authors report a new approach to this problem that involves performing a two-level osteotomy at the level of maximum spinal curvature, thereby achieving complete anatomical correction in a one-stage procedure. This 48-year-old woman with ankylosing spondylitis presented with a 30-year history of progressive neck deformity that left her unable to see ahead and caused her to experience difficulty eating, drinking, and breathing on exertion. On examination, she exhibited a 90 degrees fixed flexion deformity of the cervical spine, which was maximum at C-4; this was confirmed on imaging studies. A two-level osteotomy was performed at C3-4 and C4-5 around the area of maximum spinal curvature, and the deformity was corrected by extending the head on its axis of rotation through the uncovertebral joints. The spine was stabilized using a Ransford loop. An excellent anatomical position was achieved, as was complete correction of the deformity. A two-level midcervical osteotomy performed at the level of maximum spinal curvature in ankylosing spondylitis enables complete correction of severe fixed flexion deformity in a single procedure. Preservation of the uncovertebral joints allows smooth and safe correction of the deformity about their axis of rotation.

Anaesthetic management of posterior lumbar osteotomy

Sixty-four cases of posterior lumbar extension osteotomy performed at the Toronto East General Hospital between 1969 and 1983 are reviewed. The anaesthetic management is presented. The procedure was performed with local infiltration anaesthesia, heavy sedation and a brief period of general anaesthesia induced with nitrous oxide, halothane or ketamine. Five stages in the anaesthetic management are distinguished, each in relation to a phase of the surgical procedure and drug usage. A method of supporting these deformed patients in the prone position in moulded plaster casts is described. Anaesthetic and surgical complications and postoperative psychological disturbances are described and discussed. It is suggested that caudal epidural opioid or local anaesthetic analgesia be explored as an aid in the management of these patients.