CHAPTER
126
The Role of Osteotomies
in the Cervical Spine
INTRODUCTION
An osteotomy for the correction of a cervical deformity can be
one of the most challenging yet rewarding operations that a
spine surgeon can perform. These procedures have been asso-
ciated with catastrophic complications, including root injury,
paralysis, and even death. Hence, only highly experienced
spine surgeons should perform them. In experienced hands,
however, corrective osteotomies are relatively safe and highly
effective procedures that can have a strikingly positive impact
on patients lives. Patients with severe cervical deformities often
present to the surgeon in a markedly debilitated condition,
sometimes unable to swallow or myelopathic, and their quality
of life can be profoundly affected by the deformity. A successful
correction results in some of the most satisfied and grateful
patients in spine surgery.
In this chapter, we will discuss the role and techniques of
osteotomies for ankylosing spondylitis and iatrogenic cervical
deformity. The chapter is divided into four main sections. In
the first section, we review some historical papers on cervical
osteotomy. In the second section, which we refer to as
Preoperative and Initial Operative Approach, we will discuss
the indications, preoperative evaluation, anesthesia, position-
ing, and exposure for cervical osteotomies. Section III, Specific
Osteotomy Techniques, is divided into two broad sections: the
first part outlines the management of ankylosing spondylitis
with a chin-on-chest deformity wherein we describe our tech-
nique for performing pedicle subtraction osteotomies of the
cervical spine. The second part is devoted to iatrogenic defor-
mity correction. Section IV deals with bone grafting, wound
closure, and postoperative management.
HISTORY
Osteotomy for flexion deformity of the spine was first described
by Smith-Petersen in 1945.14 Subsequently, Mason et al reported
the first case of cervical osteotomy for fixed flexion deformity.7
In 1958, Urist demonstrated that cervical osteotomy for ankylo-
sing spondylitis could be successfully performed under seda-
tion and local anesthesia with the patient in a seated
position.17
LWBK836_Ch126_p1355-1376.indd 1355
K. Daniel Riew
Adam L. Wollowick
In 1972, Simmons published the first series of cervical exten-
sion osteotomy utilizing the technique described by Urist.13 In
his report on 11 patients with ankylosing spondylitis, Simmons
acknowledged the importance of several principles espoused
by Urist. He emphasized the need to perform the procedure at
the cervicothoracic junction due to the relatively large size of
the spinal canal at C7-T1, the mobility of the spinal cord and
eighth cervical nerves in this region, the maintenance of good
hand function in the event of C8 nerve injury, and the fairly
safe position of the vertebral artery in front of the transverse
process of C7 prior to the artery entering the transverse fora-
men at C6. The technique included laminectomies from C6 to
T1 and wide lateral decompression of the C8 nerve roots via
resection of the fused C7-T1 facet joints. Osteoclasis was then
performed using a halo with the patient under conscious
sedation.
Simmons et al more recently summarized the outcomes of
131 consecutive cases of cervical extension osteotomy per-
formed over 36 years, which represents the largest series in the
literature.12 The most notable difference was that the newer
method employed a larger area of decompression at the osteot-
omy site, including resection of most or all of the C7 pedicles.
Preoperative assessment of the extent of cervical deformity as
well as the amount of correction achieved was measured in all
patients using the chinbrow to vertical angle. A full-length
standing lateral radiograph of the entire spine with the hips
and knees maximally extended is required. The measurement
is based upon the angle created by a vertical line and a line
drawn along the patients chin and brow. A recent prospective
investigation conducted by Suk et al found that measurement
of the chinbrow angle was beneficial for planning deformity
correction and measuring treatment outcomes in patients with
ankylosing spondylitis.15
Simmons recommended performing the osteoclasis slowly
and in a controlled manner. He emphasized that excessive
force should not be necessary to achieve deformity correction.
If significant force is required, the surgeon should reassess the
area of resection to ensure that no bridge of bone remains. It
is critical to avoid overcorrection of the patients deformity. A
balance must be achieved between allowing the patient to
look straight ahead as well as to look down, such as for read-
ing or driving. Initially, attempts were made to completely cor-
rect the deformity, but Simmons ultimately recommended
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 1356 Section XI Kyphosis and Postlaminectomy Deformities
approximately 10 of residual flexion. Despite recent reports
of the use of instrumentation to help maintain head position
following cervical osteotomy, Simmons did not advocate using
implants due to the extensive osteopenia found in patients
with ankylosing spondylitis. Even with instrumentation, he
recommended a halo vest to add supplemental stability until
the osteotomy site achieved a solid fusion.
While the Simmons experience is certainly the largest pub-
lished to date, the original technique has been modified suc-
cessfully with modern anesthesia techniques, improved neuro-
physiological monitoring, and more sophisticated spinal
instrumentation systems. The first reports of successful cervical
extension osteotomy performed in the prone position under
general anesthesia with neurophysiological monitoring and
using instrumentation were published in the 1990s.8,11 Despite
the use of these advanced techniques, there was one case of
quadriparesis and two instances of pseudarthrosis among the
16 patients. More recent case reports have documented the
continued evolution of cervical osteotomy for ankylosing spon-
dylitis. Various groups have published case reports describing
the use of malleable rods to stabilize the cervical spine during
osteoclasis, gradual postoperative reduction of deformity using
Ilizarov techniques, and osteotomies performed at levels other
than C7-T1.2,4,9,10 In addition, recent developments in the tech-
nical aspects of performing the osteoclasis and stabilizing the
osteotomy have been reported. In one case, a hinged rod was
used so that the implants could be in position at the time of
osteoclasis, after which the hinge was locked to create a rigid
construct. The authors suggest that the use of such instrumen-
tation can prevent translation of the spine thereby decreasing
the risk of neurological injury.5 Another report describes using
the Jackson table to perform the osteoclasis in a controlled,
steady manner. Although this maneuver was only performed in
one patient, the authors claim that the use of incremental cor-
rection decreases the risk of subluxation that can occur during
osteoclasis performed in the traditional manner.3
Finally, several smaller series have been published that offer
additional insights into the use of cervical osteotomy to correct
fixed flexion deformity. In 2005, Belanger and Bohlman
reported on 26 patients who were treated in the manner of
Urist and Simmons and were followed for an average of 4.5 years
(range 2 to 21). All patients underwent surgery under local
anesthesia while awake in the seated position. Instrumentation
was used in 19 out of 26 patients. All patients were immobilized
in a halo cast. There were three deaths among the study sub-
jects, two of which were not attributed to the surgery. One
patient became quadriplegic following the procedure. This was
attributed to subluxation at the osteotomy site, which was also
found in four other patients. There was a significant decrease
in neck pain as well as an improvement in both swallowing and
gaze postoperatively. Preoperative neurological deficits
improved in 9 out of 10 patients, but 5 patients developed C8
radiculopathy after surgery. The average initial correction was
38 (range 15 to 84), and the average loss of correction as
documented at the final follow-up was 2.6 (range 3 of improve-
ment to 20 loss of correction).1
Another recent study specifically looked at the role of instru-
mentation and neurological monitoring during cervical osteot-
omy. The authors describe a cohort of 16 patients who had sur-
gery under general anesthesia with the use of motor evoked
potentials (MEPs) to monitor the spinal cord. Most patients
had surgery in the seated position,11 while others were prone
LWBK836_Ch126_p1355-1376.indd 1356
during the procedure.5 All had modern screwrod instrumen-
tation placed into the cervical spine. The seated patients were
immobilized in a halo cast, whereas the prone patients were
only given a cervical orthosis. All patients achieved a solid
arthrodesis without loss of correction. While there were nine
instances in which the MEP signals decreased during the proce-
dure, in six cases the potentials were recovered as a result of
intraoperative maneuvers. Of the three patients with postoper-
ative deficits, only one was left with a permanent deficit. The
authors credit the prone position with the ability to achieve dis-
tal fixation to T4 or T6, which provides a more stable construct
and obviates the need for a halo cast.6
The latest development in cervical osteotomy techniques
was described by Tokala et al in 2007. The authors report the
use of a decancellization procedure at C7 in eight patients to
correct severe fixed flexion deformity. The decancellization
uses a transpedicular approach to remove a wedge of bone
from the vertebral body. All procedures were performed in the
prone position, under general anesthesia with both SSEP
(somatosensory evoked potential) and MEP monitoring, and
with screwrod instrumentation. All patients were placed in a
halo vest postoperatively and achieved a solid arthrodesis with-
out loss of correction. There were no cases of permanent neu-
rological injury, but transient C8 radiculopathy occurred in
three patients.16
In summary, the techniques used to perform a cervical
osteotomy are continuing to evolve. While some surgeons still
prefer to perform these procedures under local anesthesia,
others are using general anesthesia with spinal cord monitor-
ing, which appears to be safe and easier for the surgeon. The
use of modern instrumentation has allowed for better fixation,
which can obviate the need for a halo vest. Finally, pedicle sub-
traction osteotomies, instead of Smith-Peterson type osteoto-
mies, are being used by more surgeons. In the following sec-
tions, we will discuss our approach and techniques for
performing cervical osteotomies, which incorporates many of
the historical procedures, but also expands upon them.
PREOPERATIVE AND INITIAL
OPERATIVE APPROACH
PRESENTATION AND INDICATIONS
Patients with ankylosing spondylitis can present with a chronic
deformity that slowly becomes debilitating for them. Alterna-
tively, they can present with an acute fracture that results in a
sudden decompensation of their cervical posture. Often these
fractures are not readily apparent on plain radiographs and
require computed tomography (CT) or magnetic resonance
imaging (MRI) to detect. A patient with complete ankylosis of
the cervical spine who suddenly experiences neck pain should
be considered to have a fracture until proven otherwise. Once
a fracture is identified, it is often easier to treat the deformity
after the fracture has healed, since these are often three-
column injuries that can be rendered even more unstable with
an osteotomy. The patient can be immobilized in a halo vest
until the fracture heals. However, this is not always possible, as
the acute deformity may result in dysphagia or an unacceptable
deformity that cannot safely be corrected with closed reduc-
tion. In such cases, we recommend performing circumferential
stabilization or, less preferably, posterior fixation followed by
postoperative immobilization in a halo vest.
8/29/11 9:37:17 PM

Although most ankylosing spondylitis cases are quite similar
(chin-on-chest deformity, osteoporosis) and require a uniform
type of osteotomy, many iatrogenic deformities are unique and
require a custom corrective approach. Patients most commonly
present with kyphosis but may also have a coronal plane defor-
mity. They may have a fusion either anteriorly, posteriorly or
circumferentially fusion. This may be with or without instru-
mentation, including anterior metal or plastic cages and even
polymethylmethacrylate. Their bone densities may be normal
or severely osteoporotic. Their soft tissues may be reasonably
intact or severely compromised due to infection or wound
dehiscence. A successful revision operation takes all of these
factors into consideration. With good preoperative planning
and meticulous attention to detail, even the most dramatic
deformities can be successfully corrected.
The most common indication for surgical correction of
ankylosing spondylitis is intolerable deformity. Other indica-
tions include compromise of the airway, abnormal esophageal
function, or neurological deficits associated with fracture or a
mobile segment. The indications for a corrective osteotomy of
the cervical spine for an iatrogenic deformity include intolera-
ble posture, neurological deficit, and intractable pain. Only the
patient can determine whether the deformity or pain is intoler-
able enough to warrant surgical treatment. Neurological defi-
cits can range from radiculopathy to profound myelopathy and
even quadriparesis.
PREOPERATIVE EVALUATION
One of the keys to successful surgery is thorough preoperative
planning. This is even more critical if one is performing a com-
plex revision cervical deformity correction. We recommend a
thorough medical evaluation, a thorough radiographic workup
with identification of any existing implants, an assessment of
soft tissue coverage, and an ENT evaluation for patients who
have had prior anterior surgery.
Patients with cervical deformities often have other medical
problems that increase the potential for perioperative compli-
cations. Patients undergoing revision surgery may have failed
their initial operation due to medical problems including dia-
betes, tobacco abuse, or infection. A thorough preoperative
medical evaluation should be performed, and any relevant
medical issues should be dealt with prior to surgery. Anemia or
coagulopathies should be corrected to the extent possible. An
osteotomy procedure in inexperienced hands can result in sub-
stantial blood loss. Therefore, if practical, one should give con-
sideration to banking autologous blood preoperatively. With
more experience, blood loss in the range of 250 cc or less is
more likely, and transfusions are rarely necessary.
A thorough radiographic evaluation can also aid in perform-
ing a successful osteotomy. Our preoperative radiographic
workup includes static and dynamic plain radiographs, long-
cassette radiographs to assess global spinal alignment, a CT
scan with sagittal and coronal reconstructions, and an MRI scan
(Table 126.1). Plain radiographs can be used to assess the
degree of deformity and any implanted instrumentation. We
obtain maximal flexionextension views to determine which
segments still retain motion. In addition, for patients with a
coronal plane deformity, we obtain lateral bending films. If
there are existing implants, it is important to identify exactly
what instrumentation was used so that the tools necessary to
remove them are available. Even if one does not plan to remove
LWBK836_Ch126_p1355-1376.indd 1357
Chapter 126 The Role of Osteotomies in the Cervical Spine 1357
Preoperative Radiographic
TABLE 126.1
Workup
Preoperative Radiographic Evaluation
AP, lateral, oblique, odontoid plain radiographs
Maximal flexionextension lateral flexion radiographs
Long cassette views of entire spine
MRI
CT with sagittal and coronal reconstructions
CT myelogram instead of CT if MRI is inadequate to visualize
neural elements
AP, anteroposterior; CT, computed tomography; MRI, magnetic
resonance imaging.
the existing implants initially, it may become necessary intraop-
eratively, and it is critical to be properly prepared. It is often
easier to calculate the angle of deformity on a preoperative CT
or MRI scan than on plain radiographs, especially with severe
deformities. Based on these radiographic evaluations, we esti-
mate the degree of correction that is required to restore bal-
ance to the cervical spine. While the chinbrow angle is also
useful, we have not found this to be practical in severe deformi-
ties, especially those involving a coronal, as well as a sagittal
deformity. In such deformities, one first has to plan the degree
of osteotomy that is necessary to achieve coronal balance. This
is most easily done on a coronally reconstructed CT or an
anteroposterior (AP) radiograph of the spine (perpendicular
to the plane of the deformity). In most cases, making the spine
perpendicular to the clavicles is ideal. However, if the patient
has a thoracic scoliosis, then an overall spinal balance that
achieves a level gaze is the goal. We then plan for the sagittal
plane correction by determining how much of an osteotomy is
required to achieve a desirable alignment. If the patient has
movement in several motion segments, and especially from the
occiput to C2, our goal is to align the posterior vertebral line of
C2 as close to the anterior vertebral line of C7 as possible. This
achieves a balanced cervical posture, provided that the thora-
columbar spine is balanced. If the entire cervical spine is fused,
we try to correct to a minimally flexed (15 to 20) cervical pos-
ture. This allows the patient without any mobile cervical seg-
ments to see the front of his or her body. An erect posture in
such circumstances may look better to the casual observer but
is highly impractical for the patient.
A high-resolution spiral CT can be used to determine if the
patient has a solid fusion both anteriorly and posteriorly. One
can also assess the accuracy and length of existing screws to
determine if these can simply be replaced with a larger diame-
ter screw. A CT scan can also provide valuable information
about the size and morphology of the C2 and thoracic pedicles.
Occasionally, a closed MRI is not possible in a patient who has
such a severe deformity that they cannot fit into the MRI tube.
In such cases, an open MRI is obviously preferable to no MRI.
We rarely find a CT myelogram necessary but do obtain it for
the rare cases when an MRI cannot be performed or is inade-
quate.
For revision cases, one must assess the soft tissues surround-
ing the spine. If the patient has had a previous anterior opera-
tion, we recommend a preoperative ENT evaluation. Even if
the original plans do not call for a repeat anterior operation, it
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 1358 Section XI Kyphosis and Postlaminectomy Deformities

is best to be prepared in case it becomes necessary. For poste- ANESTHESIA AND PATIENT POSITIONING
rior approaches, there should be an assessment of soft tissue
We use general anesthesia for all of our corrective osteotomies.
coverage. Patients who have had prior infection or wound
With modern SSEP and MEP monitoring, we believe that it is
dehiscence may only have skin covering their implants or spine.
safe and much easier for the patient as well as the surgeon to
Rarely, they may even have bone or instrumentation protrud-
perform the surgery under general anesthesia. A total IV anes-
ing through the skin (Fig. 126.1). If this is due to tenting of the
thetic is allow the use of MEP monitoring techniques. If there
skin over a kyphotic spine and some mobility remains in the
is any question regarding the integrity of the SSEP or MEP sig-
spine, we have found that immobilization of the neck in maxi-
nals at the conclusion of the osteotomy, we perform a wake-up
mal extension in a halo can result in gradual healing of the soft
test. If there is no perturbation in the monitoring data, we now
tissues. With questionable soft tissue coverage, it is prudent to
keep the patient asleep until the conclusion of the operation.
obtain a plastic surgical evaluation and to work as a team to
For the posterior osteotomies, we place the patient in a
ensure a satisfactory outcome. In most cases, the paraspinal
prone knee-chest type of position on a Jackson frame
muscles can be mobilized to cover the defect. In rare instances,
(Fig. 126.2). We use a chest bolster and two anterior iliac crest
however, plastic surgeons may have to mobilize a muscular flap
bolsters along with a sling to support the knees. Because the
to cover the wound.

Figure 126.1. This patient had numerous anterior and

posterior cervical procedures with the posterior operation
complicated by an infection. She was then referred to us for
further management. (A) A spinous processes protruding
through the skin in the midline along with friable skin sur-
rounding it. (B) Preoperative lateral radiograph shows that
she is fused in a kyphotic alignment with prominent poste-
rior instrumentation. (C) We put her into a halo with her
neck maximally extended so as to decrease the tenting of
the posterior skin. This allowed the posterior skin to heal
C gradually and once the spinous processes were fully cov-
ered, we performed a corrective procedure.

LWBK836_Ch126_p1355-1376.indd 1358 8/29/11 9:37:17 PM

 A

C B

D E

Figure 126.2. We use an OSI frame to position the patients. (A) Note that the head of the frame is on
the lowest rung of the top bracket whereas the foot part of the frame is at the lowest rung on the bottom
bracket. (B) Bivector traction with one rope going over a pulley. This is the extension rope, whereas the sec-
ond rope that is below the frame acts as inline traction for patients with severe cervical kyphosis. (C) Note
that the microscope is nearly touching the head of the bed. For this reason, it is important to make sure that
the patients head is placed at least 2 ft from the top of the bed. (D) The head is suspended with Gardner
Wells tong traction and is prepped so that there is at least 4 to 5 cm from the top of the incision to the
unprepped area. (E) The patient is positioned in a prone modified knee-chest position. Note the extreme
flexion of the cervical thoracic junction. In this case, the neck supports itself and the chin rests on the chest
bolster. A warming blanket is placed underneath the patient to keep the patient warm. This is more effective
than placing it on the back of the patient because heat rises and the ventral surface of the body loses more
heat than the dorsal surface.

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 1360 Section XI Kyphosis and Postlaminectomy Deformities
patient often has a thoracolumbar kyphosis, a prone position
on a straight table is usually impossible. In addition, we build
up the bolsters with several pillows to support the curvature of
the thoracolumbar spine. Once the patient is placed onto the
frame, we tilt the table into a maximal reverse Trendelenburg
position to allow us to operate on as level a field as possible. It
is also important to position the patients head approximately 2
ft away from the head of the table. This gives the operating
microscope enough room to maneuver without hitting the top
of the OSI table. Because the patient is placed into an extreme
Trendelenburg position, the surgeon and the assistant usually
have to stand on one or two step-up stools.
A prone position is associated with a number of potential
complications. With a patient in a reverse Trendelenburg posi-
tion, it is possible that the patients may become hypotensive.
While we prefer to keep the blood pressure at a low normal
range, hypotension can increase the risk of neurological dam-
age. Close blood pressure monitoring with an arterial line or an
accurate blood pressure cuff is therefore mandatory. We place
a Foley catheter, since the procedure is likely to take 3 to
5 hours. To prevent hypothermia we place a warming blanket
on the ventral surface of the table. Because heat rises and the
greatest loss of body heat occurs through the ventral surface,
we find that there is excellent maintenance of core body tem-
perature using this technique. In addition, we use a cell saver to
minimize the chance of the patient requiring a transfusion.
Another potential complication is air emboli that can occur
intraoperatively. Compared with a seated position, however, the
potential for air embolism is significantly lower. Another poten-
tial complication from a prolonged operation in the prone
position is blindness. The etiology of this complication is poorly
understood and may not be preventable. We make sure that the
head is hanging free and that there is nothing that can put
pressure on the orbits.
The patients head is suspended using GardnerWells tong
traction. We find this to be much more efficient and simpler
than Mayfield tongs. The tongs are attached to two separate
ropes: one that pulls the head nearly inline with the deformity
and a second rope that pulls the head into an extended posi-
tion. At the beginning of the procedure, 15 lbs are placed on
the inline traction rope. Once the osteotomy has been per-
formed and the corrective maneuver is being performed, this
weight is shifted to the extension rope. The pull of this exten-
sion vector aids in correcting the deformity. With 15 lbs, there
is enough friction across the pulleys to keep the head exactly
where one places it.
The patient is prepped from a hands breadth above and
below the expected incision site. We prophylactically adminis-
ter a first-generation cephalosporin and an aminoglycoside.
EXPOSURE
For the anterior approach, a standard SmithRobinson
approach is utilized. If there has been a prior anterior cervical
approach, an ENT evaluation is obtained to evaluate the func-
tion of the recurrent laryngeal nerve. If the nerve is intact on
the original side, then a contralateral approach is used (Table
126.2). For the posterior incision, a long midline incision is
made and we take pains to dissect very carefully in the midline
where there is an avascular plane between the paraspinal mus-
cles. Intramuscular dissection markedly increases blood loss,
and we therefore take great care to stay in the midline. This is
LWBK836_Ch126_p1355-1376.indd 1360
Algorithm for Deciding
TABLE 126.2 Which Side to Expose the
Anterior Spine in a Revision
Case
Previous Anterior Exposure Operate on Which Side?
No recurrent laryngeal nerve Opposite side
(RLN) palsy
RLN palsy Same side to avoid bilateral
injury
3 Months since first anterior Opposite side, unless RLN palsy,
operation then same side
3 Months since first anterior Either side, unless RLN palsy,
then same side
operation
carried down to the spinous processes and through the inters-
pinous process tissues, where the muscles are once again
divided in the midline. At the conclusion of the dissection,
there should not be any soft tissue left attached to the spinous
processes and laminae. The exposure is carried out just to the
lateral margin of the lateral masses. Further dissection laterally
is unnecessary and will expose large veins that can significantly
increase the blood loss.
We keep the wound well irrigated throughout the proce-
dure with antibiotic solution. Every 15 minutes or so, we irri-
gate the whole wound with approximately 100 cc of solution.
This keeps the soft tissues from drying out and washes away any
bacteria in the wound. With the final deep layer irrigation prior
to placing bone graft, we also change our outer gloves. After
each layer of closure, we also irrigate prior to closing the next
layer.
HEMOSTASIS
Intraoperatively and especially immediately prior to closing the
wound, meticulous hemostasis is achieved. With proper tech-
nique, blood transfusions are usually not necessary. Meticulous
hemostasis prior to closure diminishes the formation of postop-
erative hematomas, which may act as niduses for infection.
Bone bleeders in areas where fusion is not necessary can be
controlled with wax. In areas where a fusion is necessary, throm-
bin-soaked fibrous demineralized bone matrix or liquefied
Gelfoam rubbed into the interstices of the bone works well.
SPECIFIC OSTEOTOMY TECHNIQUES
PEDICLE SUBTRACTION OSTEOTOMY
FOR ANKYLOSING SPONDYLITIS
One of the problems with the Simmons osteotomy is that it is
an opening wedge osteotomy of the lower cervical spine. This
disrupts the anterior column of the spine and hinges on the
posterior aspect of the vertebral body. Even with multilevel
segmental instrumentation, this can result in a highly unstable
situation, which is why previous authors used supplemental
halo-vest immobilization. As an alternative to the Simmons
osteotomy, we have modified the technique of a pedicle
subtraction osteotomy that has been described for thoracolum-
bar deformities for use in the cervical spine (Fig. 126.3,
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 Chapter 126 The Role of Osteotomies in the Cervical Spine 1361

C D

Figure 126.3. These figures are of a man with ankylosing spondylitis, who presents several weeks after a
fracture causing a severe deformity. (A) This was taken with the patient lying in a supine position. Note that
the cervical spine is nearly 90 to the thoracic spine. (B) The clinical photograph of the same patient. He is
rigidly fixed in this position due to the fracture, which is mostly healed. (C) The frontal view of the same
patient. (D) The osteotomy is completed and the instrumentation is in place. Note that all of the screws in
the subaxial spine are in alignment. (continued)

Table 126.3). This technique is similar to the decancellization
procedure described by Tokala et al.16 Because it involves a
decancellization of the vertebra and shortening of the poste-
rior column, it leaves the anterior column intact, theoretically
improving the stability of the spine.
If the occipital cervical joint remains mobile, it is best to
leave this joint unfused. If, however, the occipital cervical joint
is already autofused, there are significant benefits to extend-
ing the instrumentation to the occiput. Even in the most
osteoporotic patient, the external occipital protuberance has
good bone density for screw purchase. At C2, we place either
a pedicle or a lamina screw. These are preferable to pars
screws, which are more easily pulled out. We generally prefer to
use C2 pedicle screws over laminar screws, as they are slightly
easier to attach to rods and do not require lateral connectors.
Laminar screws, however, are technically much easier and safer
to use. We prefer to use lateral mass screws at C3, C4, and C5.
C6 screws sometimes cannot be used, as they may be too close
to the T1 pedicle screws after the osteotomy is closed. This is
especially true if one uses a domino to connect a cervical system
to a thoracic system. If a domino is used, we place it instead of
a T2 screw so that a single system (cervical) bridges across the
osteotomy. We then place additional screws into T3, T4,
and occasionally T5, depending upon the purchase and

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 1362 Section XI Kyphosis and Postlaminectomy Deformities

E F

G H

Figure 126.3. (Continued) (E) We used multiple rotating dominos and thoracic spinous process screws to get
several rods across the osteotomy site to ensure rigid fixation. (F) The spinous process of C7 was split sagittally
and utilized as bone graft. (G) The pedicle subtraction osteotomy displaced anteriorly at the C7 fracture site.
(H) This was filled in with a small piece of allograft and stabilized with an anterior cervical plate. (I and J) Post-
operative day 1 clinical photographs. The patient was immobilized in a Miami-J collar for 6 weeks. (continued)

pedicle size. Most modern cervical systems now provide 4.5
mm or similar diameter screws of adequate length to utilize in
the thoracic spine such that a separate thoracic system is no
longer necessary or desirable. It is much easier to use a single
cervical system with a larger diameter pedicle screw into the
upper thoracic spine. A 3.5-mm diameter rod can be used to
fixate the spine from the occiput all the way down to the tho-
racic spine, obviating the need for dominos. At the caudal
end, we recommend six to eight pedicle screws in the thoracic
spine below the level of the osteotomy (usually at C7). A pre-
operative CT scan of the upper thoracic spine can provide
valuable information about the morphology of the upper tho-
racic pedicles.
It is critical to place all of the lateral mass screws as well as the
thoracic pedicle screws in as straight a line as possible so that the
rods easily fall into the tulip heads of the screws without requir-
ing complex coronal bends. This makes it much easier to secure
the rods to the screws after completing the osteotomy. A trial
rod insertion is performed before bending the rod in the sagit-
tal plane to make sure that it at least fits easily in the coronal
plane. If this is not done, then it may be very difficult to fit the
rod into the screw heads after performing the osteotomy.

LWBK836_Ch126_p1355-1376.indd 1362 8/29/11 9:37:56 PM

 Chapter 126 The Role of Osteotomies in the Cervical Spine 1363

I J

Figure 126.3. (Continued)

Once all of the screws have been placed, the osteotomy can
be performed. We first perform a complete C7 laminectomy.
We use a high-speed burr to cut the lamina bilaterally, just
medial to the pedicles. The lamina and spinous process is then
lifted up in one piece. The spinous process portion is then split
in half sagittally and set aside for use as bone graft material.
Next, the bottom half of the lamina of C6 and top half of the
lamina of T1 is removed using a high-speed burr. The bone
dust is saved for grafting. Care is taken to leave the spinous
processes intact. We then resect the lateral masses of C7, ini-
tially using a Leksell rongeur and saving the bone as grafting
material. The entire lateral mass, including the articular facets,
is completely removed along with the caudal portion of the
inferior articular facet of C6 and the cranial portion of the
superior articular facet of T1. The T1 pedicles must be exposed
to the extent that there is no overhanging facet cranial to the
pedicle. Any overhanging bone may compress the C8 root as
the osteotomy is closed. This exposes the C7 and C8 nerve roots
adjacent to the C7 pedicle. We then interpose a Penfield 1 and
2 to protect these nerves and use a high-speed burr to remove
the inside portion of the C7 pedicle. The walls of the pedicle
are thinned out but left intact to protect the nerve roots. The
burr is placed through the pedicle and partially into the verte-
bral body of C7 to begin the decancellization process. We uti-
lize a 2-mm matchstick burr tip, which cuts more on the sides
than at the tip. Once the central portion of the pedicle has

Comparative Advantages of Smith-Peterson Osteotomy (SPO) Versus Pedicle

TABLE 126.3
Subtraction Osteotomy (PSO)

Pedicle Subtraction Osteotomies Smith-Peterson

Stability More stable, as the anterior column is left intact.
Difficulty Increases risk of root and vertebral artery injury.
More bony resection required.
EBL Pedicle resection and vertebral decancellization
increases EBL.
Dysphagia Anterior column length unchanged, hence
esophageal length also unchanged.
Sagittal correction No advantage. Allows 6080 of correction. No advantage. Allows 6080 of correction.
Coronal correction Asymmetric decancellization allows stable correction.
Highly unstable with all three columns disrupted.
Less resection required.
Less surgery, bleeding.
Anterior column lengthens, which stretches esophagus, and
may cause dysphagia.
Only way to achieve this is by opening the wedge more on
one side, resulting in a highly unstable spine.

EBL, estimated blood loss.

LWBK836_Ch126_p1355-1376.indd 1363 8/29/11 9:38:05 PM

 1364 Section XI Kyphosis and Postlaminectomy Deformities
been decancellated and the walls have been thinned, these
walls can be fractured into the central part of the pedicle using
a small curette. During the extension osteotomy, the C7 root
may migrate into the space that was vacated by the C7 pedicle
resection. If there is any residual pedicle, root injury may
occur.
Small curettes are then used to scoop the bone from inside
the body of C7 through the pedicles bilaterally. This too can be
used later for bone grafting. Next, reverse angle curettes are
placed into the pedicles, and the cancellous bone in the poste-
rior superior portion of the C7 vertebral body is removed or
compressed into the anterior portion of the vertebral body. This
is done bilaterally. The purpose of these steps is to create a cavity
in the posterior superior portion of the C7 vertebral body. A
Woodson elevator is placed just ventral to the posterior longitu-
dinal ligament, and the dorsal cortex of the C7 vertebral body is
pushed ventrally into the cavity that was created. Because
patients with ankylosing spondylitis have osteoporotic bone, this
is quite easy to do if enough of the C7 vertebral body has been
decancellated. If the cortical wall is not easy to push ventrally,
more cancellous bone needs to be removed from within the ver-
tebral body prior to repeating this maneuver. Hemostasis is
achieved using liquefied, injectable collagen, such as Surgiflo or
FloSeal. In addition, a fibrous demineralized bone matrix, such
as Grafton Flex, soaked in thrombin can be utilized to stop
bleeding from cancellous bone. Next, the rods are prebent to a
desired angle of correction and fixed to the thoracic pedicle
screws. The surgeon then grasps the head using the Gardner
Wells tongs, and the neck is gently brought into extension. If an
adequate amount of bone has been resected at C7, little force is
required to produce a controlled osteotomy. If one cannot eas-
ily extend the neck, then more bone needs to be resected from
the ventral portion of C7. During the extension maneuver, the
C7 and 8 roots should be examined for any signs of impinge-
ment. If an adequate amount of bone has been resected, they
should remain free and mobile. Further undercutting of the C6
inferior facet or removal of any overhanging T1 superior facet
may be necessary if the C7 and C8 roots are not free.
As the head comes up, the cervical lateral mass screws will
begin to capture the prebent rods. Set screws are placed into
the tulips of the lateral mass screws as the head is extended. As
stated previously, to ensure that this part of the operation goes
as smoothly as possible, one must take care to place the lateral
mass screws in as straight a line as possible so that the rods eas-
ily fall into the tulip heads of the screws. At C2, if laminar screws
have been utilized, a lateralizing connector will be necessary to
capture the rod. All of the set screws are tightened and moni-
toring data is assessed to ensure that there are no changes. AP
and lateral radiographs are obtained. Often the osteotomy level
is not easy to see on the lateral view, but the radiograph can
give information regarding the degree of correction achieved.
With a few systems, articulated rods that have an adjustable
joint are available that make the correction even easier.
Alternatively, other systems have articulated and swiveling domi-
noes that serve a similar purpose. With either of these, both the
cervical and thoracic rods are placed into the screw heads after
the decancellization is completed. If occipital fixation is neces-
sary, then a separate rod is used and dominoed onto the cervical
portion around C2-3 or 3-4. After the decancellization is done,
the rods are tightened into the screws but the articulation is
kept loose. The neck is extended to the desired position and the
articulation is locked in place. This makes it much easier to per-
LWBK836_Ch126_p1355-1376.indd 1364
form the correction in a safe and controlled manner. We now
exclusively use such systems to correct cervical deformities.
In patients who have mobile occipital cervical joints, we stop
the instrumentation at C2. If the purchase is not deemed to be
sufficient, we turn the patient to a supine position and expose
the anterior cervical spine. We then place a plate centered at
the level of the osteotomy with, ideally, at least four screws above
and below the osteotomy site. This is also done if while perform-
ing the osteotomy the anterior column fractures or if there has
already been a fracture of C7 in the anterior column. The cir-
cumferential fixation provides a rigid and stable construct that
obviates the need for a halo vest. If the patients medical condi-
tion precludes even such a simple anterior operation, we recom-
mend immobilizing the patient in a halo postoperatively.
IATROGENIC CERVICAL DEFORMITY
CORRECTION
No chapter on iatrogenic cervical deformity can comprehen-
sively cover all of the possible permutations that the reader may
come across in clinical practice. However, basic principles can
be utilized to formulate a reasonable approach to any defor-
mity (Table 126.4). If the patient is only fused unidirectionally
(anterior or posterior), it is generally much simpler to remedy,
given that the osteotomy need only be done on that side. Unfor-
tunately, this is often not the case, even if the prior operation
had been performed from only one side. This is because with a
solid anterior fusion, the posterior facets usually begin to fuse
spontaneously within a few months. With a solid posterior sur-
gical fusion performed in kyphosis, there may be bridging ante-
rior osteophytes. For these reasons, a high-resolution
reconstructed spiral CT scan is mandatory to determine the
fusion status of each level in the spine.
Unidirectionally FusedAnterior Only
The simplest deformity to correct is one in which the fusion is
only anterior or posterior with the opposite side remaining flex-
ible. Performing an osteotomy through the fusion side then pro-
vides the flexibility necessary to realign the spine. In a patient
with a previous anterior fusion and a kyphotic deformity, the ante-
rior side is approached first. Subsequent posterior instrumenta-
tion may be necessary to augment the stability of the construct.
Wide exposure of the anterior cervical spine lateral to the
uncinates is necessary to perform the osteotomy (Fig. 126.4).
Types of Osteotomies That
TABLE 126.4 Can Be Utilized Based
Upon the Part of the Spine
That is Fused
Area Fused Osteotomy
Anterior only Anterior
Posterior only Smith-Peterson
PSO
Anteriorposterior Three-stage: P-A-P or A-P-A
Two-stage: A-P
PSO
P, posterior; A, anterior; PSO, pedicle subtraction osteotomy.
8/29/11 9:38:10 PM
 Chapter 126 The Role of Osteotomies in the Cervical Spine 1365

C5 C4 C3 C2 Penfield 4 lateral to uncinate

A B
Fusion mass exposed

C D

Vertebral body spreader

Caspar distractor Grafts in place

E F

Figure 126.4. The technique for performing an anterior osteotomy through a fusion mass. (A) The ante-
rior cervical spine is exposed from uncinate to uncinate and the longus colli is elevated off of the costal pro-
cess (anterior roof of the foramen transversarium). (B) A Penfield 4 can be used to palpate the location of
the uncinates bilaterally, which localizes the fused disc space. The burr is used to take down the fusion mass
from the left to the right uncinates. The Penfield 4 serves as a guide as to where the old disc space was and
also to define the lateral margin of the osteotomy. Once the uncinate is thinned down with the bur, then a
curette is used to remove the remaining bone. (C) Divergent Caspar distractor pins are placed. (D) With the
combination of a Caspar distractor (the distractor has been removed after getting correction) and a vertebral
body spreader, the disc space is placed into a more lordotic alignment. (E) The Caspar distractor is in place
and the deformity has been corrected. (F) Anterior grafts are placed.

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 1366 Section XI Kyphosis and Postlaminectomy Deformities
This is because the entire width of the disc space is often ossi-
fied and therefore must be drilled out. It can sometimes be
surprisingly difficult to identify where the pre-fusion disc space
used to be. One can use a c-arm to localize this or, as we do, use
anatomical landmarks. By elevating the longus colli muscles far
laterally over the costal process (the anterior roof of the fora-
men transversarium), we can identify the location of the unci-
nates. The location of the vertebral artery should have been
verified on the preoperative MRI. If it is lying anterior to the
costal process, a Penfield 2 dissector can be used to bluntly dis-
sect the longus laterally so as not to injure the artery. A Penfield
4 dissector is then used to palpate and define the lateral margin
of the uncovertebral joint. We then use a high-speed carbide
2-mm matchstick burr to take down the fusion at the level of
the original disc space. In our hands, this burr has the perfect
combination of aggressiveness with bone and safety with soft
tissues that obviates the need for a diamond burr. If there is
only a kyphotic deformity, the cut must be made perpendicular
to the long axis of the spine to prevent creating a new coronal
deformity. With a concurrent coronal deformity, this osteotomy
can be shaped asymmetrically to correct the biplanar deformity.
The bone must be removed posteriorly all the way through the
fusion mass until the posterior longitudinal ligament is visual-
ized. Even if the posterior longitudinal ligament was resected,
ventral scar tissue will prevent injury to the dural sac. To remove
the fusion mass laterally, we place a Penfield 4 lateral to the
uncinate processes to protect the vertebral artery while thin-
C
LWBK836_Ch126_p1355-1376.indd 1366
ning the bone. We then use a small curette to remove the
remaining bone. Thorough foraminotomies must be com-
pleted at all osteotomized levels to prevent root injury as the
spine is extended. Caspar distractor pins are placed with the
tips divergent so that when the distractor is placed, it creates
lordosis. The largest possible bone graft is placed to distribute
the forces across as wide an area as possible since the remaining
end plates only have cancellous bone and are prone to graft
subsidence. We use an anterior cervical plate with the longest
possible fixed angle screws to help limit subsidence. If there is
any question about the stability of the construct, we then aug-
ment the anterior procedure with a posterior arthrodesis and
instrumentation.
Unidirectionally FusedPosterior Only
If there is a previous posterior fusion with a flexible anterior
column, posterior Smith-Peterson osteotomies are performed
through the fusion mass (Fig. 126.5). Any bone between the
spinous processes is resected with a thin Leksell rongeur. Then
a burr is used to take down the facet fusion. Thorough forami-
notomies must be completed at all osteotomized levels to pre-
vent root injury as the spine is extended. Instrumentation is
placed and the neck is placed into a normal lordotic position
using the extension rope of the bivector traction as described
above for ankylosing spondylitis. As in primary posterior proce-
dures, all available fixation points should be used to ensure
Osteotomy sites
Figure 126.5. A posterior cervical Smith-Peterson osteotomy for
iatrogenic cervical kyphosis. (A) The spine is exposed with the head to
the left. The posterior spine was fused from C2 to 7 and the spinous
processes of C3-6 had been resected. (B) The fusion mass between the
facets have been taken down with a thin Leksell rongeur along with a
high-speed burr. (C) The screws are placed and the rods are bent to
the desired lordosis. A spinous process cable is placed from C2 down
to T1 and tightening this increases the lordotic correction and helps
to compress the spine. The lordotic rods are then placed and set
screws are engaged.
8/29/11 9:38:15 PM

maximal stability. If there are adequate spinous processes or
fusion mass, a cable connecting the cranial and caudal seg-
ments can be used to help extend the spine and hold it in the
desired position until the rods are engaged into the screws. Suf-
ficient bone must be removed, both to allow correction of the
deformity and to ensure that neural compression does not
occur during this step.
Two-Stage Osteotomy for Circumferentially
Fused Cervical Deformity
If the spine is solidly fused circumferentially then the options
for correction include a circumferential osteotomy or a pedicle
subtraction osteotomy. The technical details for a pedicle sub-
traction osteotomy are identical to those described above for
ankylosing spondylitis (Fig. 126.6). If a single level is responsi-
ble for most of the deformity, a pedicle subtraction osteotomy
may suffice. However, if correction is required at multiple
A B
Figure 126.6. This patient had
numerous anterior and posterior cervi-
cal procedures with a severe cervical
deformity. She presented to us after
having been in severe kyphoscoliosis
for quite some time. (A to D) Preop-
erative radiographs, magnetic reso-
nance imaging and computed C
tomography scan. (continued)
LWBK836_Ch126_p1355-1376.indd 1367
Chapter 126 The Role of Osteotomies in the Cervical Spine 1367
levels, then we prefer doing multiple circumferential osteoto-
mies. Most surgeons recommend a 540 procedure (posteri-
oranteriorposterior) for deformity correction. However, we
have found that the vast majority of these patients can be
treated with a two-stage (anterior then posterior) procedure
with similar results. The technique is possible because even
with a solid posterior fusion with instrumentation, there is still
some plasticity in the posterior fusion construct to allow some
deformation.
The initial approach is performed anteriorly to osteotomize
the anterior fusion mass, as described above (Fig. 126.7). A
greater amount of the posterior vertebral body is resected than
does the anterior, so that on a sagittal view, it appears to be a trap-
ezoidal decompression. This will allow further correction posteri-
orly, as there will be a gap between the bone graft and the poste-
rior end plates. Four Caspar distractor pins are then placed across
the osteotomy site: two on the right side and two on the left. In
addition, a vertebral body spreader can be placed into the disc
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 1368 Section XI Kyphosis and Postlaminectomy Deformities

E F

Figure 126.6. (Continued) (E and F) Clinical photographs. (continued)

LWBK836_Ch126_p1355-1376.indd 1368 8/29/11 9:38:22 PM

 G C D

Pedicle Cord Cord C6 and C7 Roots

H I

C6 and C7 Roots

J K
C6 and C7 Roots
Figure 126.6. (Continued) (G) This illustrates the technique for a pedicle subtraction osteotomy for iatrogenic cervical kyphosis. The tech-
nique is identical to that for ankylosing spondylitis. We favor this technique as an anteriorposterior osteotomy in this case would have necessi-
tated burrowing through the anterior metallic cage. The first step is to completely cut the lamina as well as the facet as described for ankylosing
spondylitis. Then a burr is used to hollow out the central portion of the pedicle. Next, the pedicle walls are removed with a reverse angle curette.
Then we burr the superior posterior portion of the vertebral body with a burr followed by a tamp and a curette to remove some bone as graft
material. These steps are illustrated with intraoperative pictures in H through K. (H) Drilling the pedicle down. (I) Removing the pedicle walls.
(J) Drilling out the vertebral body. (K) Decancellating the body. (continued)

1369

LWBK836_Ch126_p1355-1376.indd 1369 8/29/11 9:38:25 PM

 1370 Section XI Kyphosis and Postlaminectomy Deformities

L M

N O P

Figure 126.6. (Continued) (L to N) Postoperative radiographs. (O and P) Clinical postoperative

photographs.

space. The disc space is then gradually distracted one click at a
time, using all three devices. If the posterior fusion mass is not
massive, it often has sufficient plasticity such that placing enough
extension moment on the anterior spine can bend it. Slow, steady
distraction causes plastic deformation of the posterior fusion mass
and achieves relative extension across the osteotomy. By slowly
performing this maneuver, one can often extend the disc space
by 3 to 5 mm. The vertebral body spreader is then removed, and
a structural graft is placed in the anterior half of the disc space
that has been created. A structural graft, shaped with the anterior
height taller than the posterior, is sized to fit snugly into the
expanded osteotomy site. The ideal graft has good contact with
the anterior aspect of the vertebral bodies but has some room to
settle into further lordosis following the subsequent posterior
osteotomy. The graft should only occupy approximately the ante-
rior two thirds of the vertebral body so that there is no chance of
retropulsion during the posterior operation. One should also
take care to ensure that the posterior aspect of the end plates
behind the graft is not touching, since one can get further exten-
sion after the dorsal osteotomy. A dynamic cervical plate, with
12-mm variable angle screws, which allows for translation and fur-
ther lordosis, is then used to hold the graft in place. An alterna-
tive is a small buttress plate placed on the cranial side of the
osteotomy. If it is placed on the caudal side, the top of the plate

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A B
Figure 126.7. Figures of a patient with severe kyphotic deformity and myelopathy. (A to C) Preoperative
radiographs and magnetic resonance images. (continued)
appears to be proud and impinging on the esophagus after the
posterior correction. Another alternative is to use two or more
plates, depending upon how many levels are addressed anteriorly
(Fig. 126.8). A drain is placed and the anterior wound is closed.
The patient is then turned to a prone position, and the pos-
terior osteotomies are performed. By placing the graft on the
anterior portion of the disc space during the anterior operation,
one can hinge off of this graft and extend the spine after remov-
ing the dorsal fusion mass. Using this technique, we can usually
avoid having to perform a three-part operation with an anterior,
posterior, followed by a repeat anterior operation. The only
exception to this has been when we did not place a plate ante-
rior to the graft to prevent it from extruding. When we extended
LWBK836_Ch126_p1355-1376.indd 1371
Chapter 126 The Role of Osteotomies in the Cervical Spine 1371
the spine posteriorly, the anterior disc space gapped open, and,
with the patient prone, partial graft extrusion occurred, neces-
sitating a repeat anterior exposure to push the graft back in
place. As a result of that case, we now make sure that there is a
plate blocking every graft that we put in the anterior spine.
BONE GRAFTING, WOUND CLOSURE,
AND POSTOPERATIVE MANAGEMENT
BONE GRAFTING
In general, osteotomies rarely develop pseudoarthroses, so long
as the osteotomized segments are intimately reapproximated. If
8/29/11 9:38:37 PM
 1372 Section XI Kyphosis and Postlaminectomy Deformities

D F

Figure 126.7. (Continued) (D) A needle is placed intraoperatively to serve as a guide to demonstrate what
angle the burring must be done to osteotomize the disc space. With some practice, we prefer it to using intra-
operative C-arm guidance, but it is easy to wander away from the disc space and into the midvertebral body.
Alternatively, a Caspar pin can be placed to serve the same purpose (see Fig. 126.8E below). (E) Double trap-
ezoidal grafts that are undersized are placed into the disc space after distracting the disc space with two Cas-
par distractor pins. Alternatively, one Caspar distractor pin and a vertebral body spreader can be utilized.
Occasionally one has to use two Caspar distractor pin sets along with a vertebral body spreader, if the bone is
osteoporotic and/or there is a large posterior fusion mass. (F) The anterior operation is completed. There is
only partial correction of the deformity as the patient still has a fused posterior cervical spine. (continued)

a posterior osteotomy has been completed correctly, with
exactly the correct amount of bone resected, then it should
heal without any bone grafting. The reality, however, is that
occasionally with pedicle subtraction osteotomies more bone
has been resected than necessary and a gap remains between
the residual lateral masses. To ensure proper healing, we use
local bone graft to enhance the fusion. For example, after a
pedicle subtraction osteotomy for ankylosing spondylitis, the
spinous process of C6 should be in close proximity to the
spinous process of T1. These are minimally decorticated, and
the spinous process of C7 that had been split in half sagittally is
placed on the sides of the two spinous processes and cabled in
place. The remaining C7 laminectomy bone is used to cover the
defect between the C6 and T1 laminae. If there is inadequate

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I
bone, one of the upper thoracic spinous processes can be
resected, split, and used to cover the dura to prevent small
bone pieces from falling into the defect. The rest of the autolo-
gous local bone graft is then placed over this. If there is a gap
between the C6 lateral mass and T1, it can be covered with a
structural piece of bone from one of the thoracic spinous pro-
cesses. The bone is first decorticated on the undersurface where
it contacts the spine and contoured to fit around the screws.
With anterior osteotomies, an interposing structural graft
has to be placed into the osteotomy site. Therefore, the inci-
dence of pseudarthrosis is similar to that of an anterior cervical
discectomy and fusion (ACDF). A circumferential fusion rarely
develops a pseudarthrosis. Therefore, if the patient is at high
risk for pseudarthrosis, consideration should be given to per-
forming a circumferential procedure.
DRAIN AND CLOSURE
The anterior wound is closed and drained as per the surgeons
choice, but the posterior closure deserves a word of caution.
LWBK836_Ch126_p1355-1376.indd 1373
Chapter 126 The Role of Osteotomies in the Cervical Spine 1373
Figure 126.7. (Continued) ((G) Using cables, as
described previously, we can extend the C2-3 level further
and lock it in with posterior instrumentation. (H and I)
Postoperative radiographic images.
Posterior wound closure is often a neglected part of the opera-
tion. If an inadequate number of drains are used hematomas,
which may serve as niduses for infection, can form. A poor clo-
sure can increase the infection rate, lead to dehiscence and, at
the very least, result in a poor cosmetic result. We pay as much
attention to the closure as we do to the exposure and osteot-
omy and have seen few wound complications.
While closing the posterior wound, suturing often causes
bleeding from the vessels in the muscles. We coagulate all such
bleeders prior to tying the knot. We then compress the wound
after each layer of closure for 1 to 2 minutes. The extra time
and care that we take during the closure significantly decreases
the amount of postoperative drainage and, hence, the hospital
stay. We are able to discharge the majority of these patients
within 24 hours after surgery.
We use at least two and sometimes three drains in all long
(greater than three level) posterior cervical exposures. The
first is placed over the spine and several layers are closed. Then
the second drain is placed in the intermediate layer below the
fascia. Often, a part of this drain can also be left superficial to
8/29/11 9:38:41 PM
 1374 Section XI Kyphosis and Postlaminectomy Deformities

Figure 126.8. Figures of a patient who is status post ante-

rior cervical discectomy and fusion at C5-6-7 with autofusions
posteriorly from C3-7 with severe kyphotic deformity and myel-
opathy. She also has severe facet arthrosis below C7. (A to D)
Preoperative radiograph, magnetic resonance imaging and
C
computed tomography (CT). (continued)

the fascia to drain that layer as well. Both of these are eighth-
inch Hemovac drains that are connected to the same reservoir.
In an obese patient, we usually use a third drain in the subcuta-
neous fatty layer. We usually use an eighth-inch Blake drain
attached to a bulb.
For a long posterior cervical incision from C2 to the upper
thoracic spine, we close the layers ventral to the fascia with
no. 1 Vicryl pop-off sutures. Small bites are taken through the
muscle layers to prevent muscle necrosis and multiple sutures
are placed approximately 1 to 2 cm apart. We typically use
somewhere between 30 and 50 no. 1 Vicryl pop-off sutures to
close the deep layers. This prevents muscle and fascial dehis-
cence and closes any potential dead space where hematomas
can form. Next, we use another 20 to 30 2-O Vicryl pop-offs to
close the suprafascial and subcutaneous layers. Finally, we use
3-O Monocryl sutures for the final subcuticular closure. With
a combination of copious irrigation, multiple drains, and
meticulous hemostasis during opening and closure, our infec-
tion rates for posterior cervical procedures have fallen to less
than 1%.

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 Chapter 126 The Role of Osteotomies in the Cervical Spine 1375

D E

F G

Figure 126.8. (Continued) (E) Intraoperative radiograph with the Caspar pins in place. These are initially
used to localize and to determine the angulation of the former disc space. Afterwards, they are used to dis-
tract the osteotomy site. (F and G) Postoperative lateral radiograph and CT. Note that we utilized two plates
anteriorly. These are used as buttress plates to prevent graft extrusion at C2-3 and over the C5 corpectomy
osteotomy site. Using the two plates allows complete freedom to extend the neck at the osteotomy site poste-
riorly without having an anterior bridging plate acting as a tension band to prevent correction. One error
that we made in this case was that we did not adequately decompress the C4-5 foramen when we did the pos-
terior osteotomy, prior to extending the neck. This resulted in a postoperative C5 palsy unilaterally. We
elected to observe this and it resolved fully over a couple of weeks. We now pay greater attention to the
osteotomy site to ensure that there is no root compression as we extend the neck.

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 1376 Section XI Kyphosis and Postlaminectomy Deformities
POSTOPERATIVE MANAGEMENT
The head of the bed is elevated to about 30 to 40. This mini-
mizes blood loss and accommodates the patients typical thora-
columbar kyphosis. For the first several circumferential
osteotomy cases, the anterior procedure may take 4 to 6 hours
or more, with the posterior taking another 4 to 6 hours. With
such prolonged procedures, the patient should be kept intu-
bated for airway protection. With experience, these times sig-
nificantly decline to 2 to 3 hours for the anterior and a similar
time for the posterior, such that the patient can usually be extu-
bated safely. If there is any concern about airway edema, a cuff
leak test should be performed prior to extubation and consid-
eration should be given to keeping the patient intubated over-
night for airway protection. Posterior pedicle subtraction
osteotomies take a bit longer than a Smith-Peterson osteotomy
but with experience, these can usually be completed in approx-
imately 3 to 5 hours.
For ankylosing spondylitis patients, if the screw purchase is
excellent or the instrumentation extends to the occiput, we
typically immobilize these patients in a Miami-J collar only. We
also use the same collar if we have performed circumferential
instrumentation. For iatrogenic cervical deformity patients with
good bone density and circumferential fixation, we often use a
soft collar.
The drains are kept in place until they put out less than 20
cc for an anterior drain and 30 cc for the posterior drains in an
8-hour shift. Antibiotics are continued until all drains are out.
The patients are ambulated 1 day postoperatively and are typi-
cally discharged within 24 to 48 hours postoperatively. Another
key to early discharge is adequate pain control with a combina-
tion of oral medications on which they are to be discharged.
CONCLUSION
Cervical osteotomies can be some of the most challenging pro-
cedures that one can perform. Fortunately, with modern instru-
mentation, anesthesia, and neurophysiologic monitoring
techniques, these procedures have become much safer, allowing
LWBK836_Ch126_p1355-1376.indd 1376
surgeons to tackle more complex deformities while achieving
ever greater corrections than in the past. Nevertheless, any sur-
geon attempting to correct these complex deformities must
approach these cases with the utmost care and due diligence.
Only meticulous preoperative preparation and hypervigilant
intraoperative techniques will minimize the chances of an
intraoperative or postoperative disaster.
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