Surgical strategies for the treatment of deformity-associated cervical spondylotic stretch myelopathy: a case series with technically nuanced illustrative operative videos.

OBJECTIVE: The aim of this study was to elucidate the vital role of anterior-only osteotomies for rigid cervical kyphosis causing stretch myelopathy by using illustrative cases and high-definition intraoperative videos. METHODS: The authors describe 4 select patients who underwent anterior-only osteotomies within a 2-year time frame and demonstrate the nuances of each case with unique operative videos. RESULTS: Outcomes for each of the cases demonstrated marked improvement in cervical spine alignment relative to preoperative conditions. Postoperative CT scans and upright radiographs for case 1 at 8 months demonstrated complete reduction of the kyphotic deformity and restoration of the C2 slope. In case 2, the 2-year postoperative radiographs showed significant realignment of the cervical spine, and the patient made significant neurological improvement since the operation, specifically in hand dexterity, balance, neck pain, and the ability to comfortably achieve and maintain a horizontal gaze. For case 3, postoperative upright radiographs revealed marked improvement in the patient's cervical sagittal alignment. The 4-month follow-up was also notable for substantial improvement in postural neck pain, bilateral upper extremity strength, and continued improvements in dexterity. Case 4 also demonstrated an excellent outcome with unkinking of the patient's spinal cord and correction of her sagittal plane deformity, as shown on her 5-month postoperative upright radiographs. CONCLUSIONS: Deformity-associated cervical spondylotic stretch myelopathy often leads to devastating neurological decline and can significantly decrease quality of life. Carefully selected cases of circumferentially rigid cervical kyphosis can be successfully corrected with anterior-only osteotomies followed by posterior fixation while avoiding back-front-back operations.

The "Inside-Out" Anterior Osteotomy of the Proximal Femur via the Direct Anterior Approach in Revision Hip Arthroplasty.

Osteotomy techniques used for wide exposure during femoral component revision include the extended trochanteric osteotomy and its modifications. We describe an anterior proximal femur osteotomy technique starting from the inside of the femoral canal at the bone-implant interface and heading outward. The technique is used in conjunction with the extended direct anterior approach and allows direct access to and visualization of the anterior, medial, and lateral bone-implant interfaces. This technique is most useful for the removal of collared, fully hydroxyapatite-coated double-tapered femoral stems, in which bone-implant interfaces need to be accessed for removal of a well-osseointegrated hip arthroplasty implant.

Assessment of the anterior osteotomy role in the restoration of normal pelvic floor anatomy for bladder exstrophy patients using pre and postoperative pelvic floor MRI.

OBJECTIVE: Our aim was to evaluate the effectiveness of anterior osteotomy in the restoration of normal pelvic floor anatomy in classic bladder exstrophy repair using pelvic floor MRI as an imaging tool for evaluation. PATIENTS AND METHODS: This study is a pilot prospective randomized controlled study that included 20 infants with classic bladder exstrophy older than three months with no history of previous surgical operations. All patients underwent complete primary repair and were randomized into two groups, with or without osteotomy. Both groups were assessed preoperatively & postoperatively after three months with pelvic floor MRI and compared to age & gender-matched control group infants with normal pelvic anatomy infants who underwent pelvic MRI for other medical conditions. RESULTS: There was not any significant statistical difference between osteotomy and non-osteotomy groups in pre-operative demographic data and all pelvic floor MRI measurements, emphasizing that both groups were equal in all characters at the start point of the study before the operation. The mean change difference between pre-operative and post-operative pelvic floor MRI measurements were compared in both groups, and there was not any significant statistical difference in all pelvic floor MRI measurements. Both groups showed the same statistical significance when compared with the control group in all pelvic floor MRI measurements except the posterior bladder neck distance, which was in favor of the osteotomy group, closer to the normal pelvic floor anatomy. CONCLUSIONS: Anterior osteotomy did not have a significant difference in the restoration of the normal pelvic floor anatomy when combined with complete primary repair of classic bladder exstrophy in newly diagnosed neonates older than three months, except for a single measurement, posterior bladder neck distance. Future studies needed to determine the effect of osteotomy on continence.

Double-level myelopathy due to atlantoaxial dislocation (os odontoideum) and subaxial cervical spondylosis with angular kyphosis.

BACKGROUND: The surgical management of cervical spondylotic myelopathy (CSM) attributed to os odontoideum (OO with atlantoaxial instability atlantoaxial instability) and subaxial kyphosis together pose significant surgical challenges. CASE DESCRIPTION: An elderly male presented with CSM/myelopathy and severe quadriparesis attributed to an unstable OO and 87° fixed, subaxial cervical kyphosis. After performing a 540° spinal cord decompression with atlantoaxial fixation, the patient did well. CONCLUSION: Double-level CSM due to an unstable OO and subaxial kyphosis is rare and typically requires combined 540° decompression and stabilization.

Anterior cervical osteotomy: operative technique.

PURPOSE: Correction of rigid cervical deformities often requires osteotomies to realign the spine. Cervical pedicle subtraction osteotomy can be technically challenging due to the presence of cervical nerve roots and usually can only be performed at C7 or T1 due to the presence of vertebral arteries. In contrast, anterior cervical osteotomy can be performed throughout the cervical spine and is a safe and effective method for correction of both sagittal and coronal cervical deformities. We describe the anterior cervical osteotomy technique with a review of the pertinent literature. METHODS: A step-by-step technical guide for anterior cervical osteotomy is provided with a focus on surgical nuances and complication avoidance. Two illustrative cases of fixed sagittal and coronal deformities are included to demonstrate the substantial amount of deformity correction achievable using the anterior cervical osteotomy technique. RESULTS: Both patients in the illustrative cases had successful clinical and radiographic outcome following deformity correction utilizing the anterior cervical osteotomy technique. CONCLUSION: Anterior cervical osteotomy is a safe and effective technique for correction of rigid cervical deformities. Spine surgeons should be familiar with this technique to optimize clinical outcome in patients undergoing cervical deformity correction.

Correction of dropped head deformity through combined anterior and posterior osteotomies to restore horizontal gaze and improve sagittal alignment.

OBJECTIVE: The aim of this study is to present our technique for a large focal correction of a partially flexible dropped head deformity through combined anterior and posterior osteotomies, as well as anterior soft tissue releases. METHODS: One patient with dropped head deformity underwent an anterior and posterior osteotomy with anterior soft tissue release. RESULTS: The patient recovered well, with postoperative radiographs demonstrating significant improvement in coronal and sagittal alignment. His C2-C7 sagittal vertical axis improved from 7.5 cm preoperatively to less than 4 cm postoperatively and his C2-C7 sagittal Cobb improved from 35° of kyphosis to 10° of lordosis. CONCLUSION: In this report, we present our technique for a large focal correction of a partially flexible dropped head deformity through combined anterior and posterior osteotomies and anterior soft tissue releases. These more conservative osteotomies permitted gradual deformity correction and alleviated the need for pedicle subtraction osteotomy. We were able to restore horizontal gaze and improve sagittal malalignment. Although the technique we present here is one of many possible options for managing the deformity, we believe this combined approach is safe and effective and well tolerated by patients.

Cervical Spine Deformity-Part 3: Posterior Techniques, Clinical Outcome, and Complications.

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications. Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

Cervical Spine Deformity-Part 2: Management Algorithm and Anterior Techniques.

A sound operative plan based on solid understanding of the pathology and biomechanics is the most important part of cervical deformity correction. 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 often controversial. In Part 2 of this three-part review series, we discuss the pre-operative planning, management algorithm, and anterior surgical techniques for cervical deformity correction.

Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification.

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. 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. We aim to provide an overview of cervical spine deformity in a 3-part series covering topics including the biomechanics, radiographic parameters, classification, treatment algorithms, surgical techniques, clinical outcome, and complication avoidance with a review of pertinent literature.