The use of traction methods to correct severe cervical deformity in rheumatoid arthritis patients: a report of five cases

Non-instrumented correction of cervicothoracic kyphosis in ankylosing spondylitis: a critical analysis on the results of open-wedge osteotomy C7-T1 with gradual Halo-Thoracic-Cast based correction

INTRODUCTION

With progression of cervicothoracic kyphosis (CTK), ankylosing spondylitis (AS) patients suffer functional disability. Surgical correction still poses neurologic risks, while evidence of an ideal technique preventing its complications is weak.

MATERIALS AND METHODS

We report our results with non-instrumented correction in perspective of a review of literature, serving as an important historical control. Database review identified 18 AS patients with CTK correction. After application of a Halo-Thoracic-Cast (HTC) patients underwent posterior non-instrumented open-wedge osteotomy at C7/T1 and osteotomy closure by threaded HTC-rod adjustments. Postoperative gradual HTC correction was continued for 2-4 weeks. Patients were invited for follow-up and medical charts were reviewed for demographics, surgical details, complications and outcomes. The patients' preoperative, postoperative, before HTC removal and follow-up photographs were analyzed for the Chin-Brow-Vertical-Angle (CBVA), radiographs for the CTK angle.

RESULTS

Patients' age was 50 ± 11 years, follow-up was 37 ± 47 months and CBVA correction was 25° ± 9° (p < 0.000001). The final radiographic correction at follow-up was 20° ± 11° (p = 0.00002). At the latest follow-up, three patients judged their outcome as excellent, nine good, three moderate and one poor. Upon invitation, seven patients appeared with follow-up averaging 87 months. Neck-pain disability index was 8 ± 14 %. Two patients died, three were lost, one had revision elsewhere and five just had a routine follow-up. Six patients sustained a minor and ten a major complication. Revisions were indicated in five patients including infection, C8-radiculopathy and neurologic events by translation at the osteotomy. A total of 44 % of patients showed translation at the osteotomy indicating acute surgery with instrumentation twice after osteotomy closure, three patients had a revision posterior decompression and instrumented fusion for sequels related to translation.

CONCLUSION

With the non-instrumented HTC-based technique, average CBVA correction of 25° was achieved and all patients were ambulatory at follow-up. However, regarding translation at the osteotomy, loss of correction, morbidity of the HTC and lack of control at the osteotomy instrumentation-based correction and instrumented fusion seem to be preferable.

Rapid magnetic resonance imaging-guided reduction of craniovertebral junction deformities

The authors demonstrate the utility of an MR imaging-compatible traction board for the rapid reduction of craniovertebral junction (CVJ) deformities. To choose the appropriate surgical management, patients with compressive CVJ deformities often undergo a trial of traction. Conventional traction trials require the treating surgeon to infer from plain radiographs the manner in which traction forces affect neural and ligamentous structures at the CVJ. To avoid overdistraction injury, low increments of weight are added in a gradual fashion, a process that typically requires 48-72 hours. The authors outline the use of an MR imaging-compatible traction board to determine reducibility safely and rapidly in 4 patients with compressive CVJ deformities. Four patients with advanced CVJ deformities underwent a trial of MR imaging-guided traction performed using an MR imaging-compatible spine board. Serial sagittal images were acquired at baseline and following each sequential addition of force. All patients tolerated traction without neurological worsening. The neural elements were seen to be adequately decompressed in all cases during a single MR imaging session. Patients subsequently underwent craniocervical stabilization and fusion. Postoperative imaging showed maintenance of the reduction without neural compression. An MR imaging-guided trial of traction can facilitate the rapid and safe determination of the reducibility of compressive lesions in patients with advanced CVJ deformities. Rapidly acquired sagittal MR images permit the surgeon to evaluate the effects of traction on the soft tissues at the CVJ, thereby expediting the traction trial and avoiding the risks of immobility in this often-fragile patient population.

Complex Deformities of the Cervical Spine

Cervical deformities arise from a multitude of causes, including genetic, congenital, inflammatory, degenerative, and iatrogenic etiologies. They often require surgical intervention for treatment of pain, progressive structural decompensation, and neurologic deterioration. 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. 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. 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.