Introduction: Cervical kyphosis is failure of posterior osteo-ligamento-muscular restraint secondary to a deficient anterior column. Prospective studies of stand-alone anterior construct in correction and maintainence of cervical column that would otherwise require combined ant & post surgeries is sparse.

Objectives: To evaluate the role of stand-alone anterior surgery for cervical kyphosis, determine its efficacy and analyse complications.

Methods: 42 consecutive patients aged 6 – 70 yrs (Av 31.4 yrs) who had a Kyphosis angle of more than 100 with its apex between lower end-plate of C2 and C7 on a lateral x-ray and underwent anterior only surgery for cervical kyphosis over 6 yrs (2000–06) formed the population for this prospective study. The average follow-up was 2.2 yrs (1 – 5 yrs). The mean pre-op kyphosis was 20.820 (100 – 780). Etiology was tuberculosis in 25, dysplasia in 7, trauma in 6 and tumors in 4 cases respectively. 39 of the 42 patients had myelopathic signs. Mean pre-op mJOA score was 7.4 (0–11). A left anterior cervical approach was used in all cases. Modified manubriotomy was required in 5 cases to instrument the caudal vertebra. Tricortical iliac crest strut graft was used in 40 and cylindrical mesh cage in 2 cases. Correction of kyphosis was achieved by intra-op adjustment of the head assembly & controlled distraction. Post-operatively all wore cervical orthosis for 3 mo.

Results: 41 patients were available for analysis (1 lost for f/u). The average number of corpectomies required were 2.5 (1–4) and the mean anterior column defect reconstructed was 27.3mm (22–42mm). The average graft subsidence was 3mm (0–10mm). 2 patients required revision surgery within 6 weeks for implant failure/graft resorption. Fusion occurred in rest of 39 patients. No further graft subsidence was noticed at 4 years in 17 patients. Spontaneous fusion at 3 mo was seen in normal adjacent segment due to plate overlapping in 2 cases. The average correction achieved was 15.220 (−40–730). The mortality rate was 2.12% (1 case). Visceral complications occurred in 3 cases (esophageal perforation in 1 and recurrent laryngeal nerve palsy in 2). The mean post-operative mJOA score was 14 (9 – 17). There was 1 deep and 1 superficial infection.

Conclusion: Ant decompression & reconstruction with instrumentation facilitates neurological recovery restoring alignment. Intra-op maneuvering allows the graft to be placed in an optimal position that allows fusion under compression.

Introduction: Formulation of surgical protocol in CSM is marred by the diversity in clinico-radiological presentation. Prospective data that assigns a specific surgery with identifiable similarities in clinico-radiological attributes is sparse.

Objectives:

To identify radiological patterns of compression (POC) of the spinal cord

Methods: 135 consecutive patients aged 32–75 yrs (mean 48.1yr) operated for CSM from 1999–2005 formed the study group for this prospective series. The objectives were to identify radiological patterns of compression (POC), develop a surgical algorithm based on POC and evaluate outcome. Four POC were identified on MRI.

Pattern I – predominant one/two level compression in normal/narrow canal

Mean follow-up was 3 yrs (2–8). ACDF was performed for patterns I, II & III and posterior decompression for pattern IV and III(A). For pattern IV(A), a two stage primary posterior decompression followed by targeted ACDF at the site of maximal compression was performed. The clinical outcome was measured by modified JOA (mJOA) score, Hirayabashi Recovery Rate (HRR) and functional outcome by modified Neck Disability Index (NDI).

Results: The mean pre & post-op mJOA score was 10.40±3.33 & 15.76±1.45 respectively with average HRR of 80.10 ± 26.38. The difference in the mJOA scores was statistically significant (unpaired t test) for each POC. In multilevel CSM, anterior surgery in POC type III had statistically better post op mJOA as compared to those who underwent posterior surgery viz POC types IV and III & IV variants although the difference in their HRR and NDI were not statistically significant.

Conclusion: Anterior surgery has better neurological outcome in judiciously selected patients with multilevel CSM. Surgical decision-making guided by patterns of compression (POC) is pivotal for optimal functional outcome.

Rigid angular kyphotic deformities of the spine have been corrected by staged anterior and posterior procedures. This paper evaluates the efficacy of single stage transpedicular decancellation, vertebral column mobilization and spinal shortening in the correction of rigid THORACIC kyphotic deformities in adolescent patients.

Between 1993 and 1999, 21 patients with rigid kyphosis underwent deformity correction using the above procedure. The deformity was thoracic in 6 patients, thoraco-lumbar in 14 and lumbar in one patient. This report focuses on 6 patients with thoracic deformity. The etiology in 5 patients was due to tuberculosis while one patient had a congenital anomaly. There were 4 females and 2 male patients. The average age was 12 years. The average kyphosis was 75 degrees (38 – 135 degrees). Of the 6 patients, 2 had preoperative paraplegia. All cases were assessed using CT and MRI scans in addition to plain radiographs. The surgical technique utilized the principle of transpedicular decancellation through a single posterior midline exposure in the prone position. Following complete decancellation of the apical vertebrae, the proximal and distal vertebral column was adequately mobilized to enable spinal shortening along with anterior translation. Segmental spinal instrumentation was used to achieve stable fixation.Intraoperatively, the wake-up test was used to assess the neurological function. This was followed by anterior interbody fusion and posterolateral fusion. At an average follow-up of 36 months, average kyphosis correction was 61% and all cases were adequately fused. Both cases with paraplegia recovered completely. The average loss of correction was 6 degrees. One patient developed hyperlordosis below the corrected level. This was revised by extending the spinal fixation to include the lower levels. In conclusion, the above procedure is used as a last resort for correction of rigid angular deformities. It is a safe but demanding procedure. Spinal column shortening is essential to avoid neurologic compromise and balance the column.

Craniovertebral tuberculosis accounts for 5% of all cases of tuberculosis and is the commonest infective pathology affecting this region. There are very few published reports discussing the presentation and management of this complex pathology.

30 cases of craniovertrebral tuberculosis treated between 1989–97 were reviewed retrospectively. The average age was 24 years (range 6 – 42 years) with a follow up of 41 months (range 36 – 48 months). Two main groups on the basis of atlantoaxial stability. 18 (60%) had an unstable atlantoaxial articulation and of these 12 (66%) had a fully reducible AAD in extension. 17 patients (56%) had varying degrees of neurological deficit with lower limb spasticity being the commonest.

Antituberculous chemotherapy, skeletal traction in extension and prolonged bracing with moulded philadelphia collar were main stays of conservative treatment. Surgery in the form of posterior occipito cervical arthrodesis was needed in 13 patients (43%) and indications included incompletely reduced AAD, non resolving neurological deficit and persistent instability despite 6 weeks in traction.

There was 93% success rate with resolution of infection (range 4 – 8 months) and improvement in neurological deficit 2 patients had incomplete neurological recovery and required 2^nd stage anterior transoral odontoidectomy. Management strategies based on the presence or absence of instability and neurological deficit can give a very satisfactory outcome with judicious combination of drug therapy, bracing and surgical decompression with fusion.