Osteotomies for the

Treatment of Cervical Kyphosis Caused by

Ankylosing Spondylitis: Indications and Techniques
Adam L. Wollowick, MD,* Michael P. Kelly, MD,† and K. Daniel Riew, MD†

Ankylosing spondylitis is an inflammatory disorder that can produce disabling musculosk-

eletal conditions. Spinal deformity is among the most common manifestations. Cervical
kyphosis can be particularly debilitating to the patient because of interference with forward
gaze and activities of daily living. In addition, cervical deformity can lead to both neurologic
and respiratory deterioration. For many patients, the only treatment option is surgery. Both
the Smith-Petersen osteotomy and the pedicle subtraction osteotomy have been used
successfully to manage cervical deformity in patients with ankylosing spondylitis. These
procedures are technically difficult and carry significant risk but can produce excellent and
safe outcomes.
Semin Spine Surg 23:188-198 © 2011 Elsevier Inc. All rights reserved.

KEYWORDS cervical spine, spinal deformity, kyphosis, ankylosing spondylitis, Smith-Petersen

osteotomy, pedicle subtraction osteotomy

A nkylosing spondylitis (AS) is an inflammatory disorder

that can cause a variety of debilitating orthopedic prob-
lems. Among the many musculoskeletal manifestations of AS,
Pathophysiology

spinal deformity is perhaps the most disabling to the patient.
The rigid kyphosis that occurs in advanced cases of AS can
interfere with all aspects of daily life, including forward gaze
and ambulation. This is especially true if the patient develops
fixed flexion of the cervical spine, which may ultimately lead
to a chin-on-chest deformity (Fig. 1). Patients with this con-
dition often have few viable treatment options other than
surgery. The surgical management of fixed cervical kyphosis
because of AS can be intimidating for both the experienced
spinal surgeon as well as the patient. Nevertheless, both the
Smith-Petersen osteotomy and the pedicle subtraction os-
teotomy (PSO) have been used successfully in the manage-
ment of severe cervical kyphosis. Although these procedures
are associated with significant risks, they can be performed
safely and can generate a satisfying outcome for both the
patient and the surgeon.
*Department of Orthopaedic Surgery, Montefiore Medical Center/Albert
Einstein College of Medicine, Bronx, NY.
†Cervical Spine Service, Washington University Orthopedics, St.
Louis, MO.
Address reprint requests to K. Daniel Riew, MD, Department of Orthopedic
Surgery, Washington University School of Medicine, 660 South Euclid
Ave, Campus Box 8233, St. Louis, MO 63110. E-mail: riewd@wudosis.
wustl.edu
Although the etiology of AS is unknown, the disease process
is attributed to systemic, chronic inflammation. In particular,
AS causes an enthesopathy, which is characterized by an
abnormal, inflammatory response at the site of ligament and
tendon attachments to bone. Pannus formation and destruc-
tion of bone occur, which can ultimately result in fibrosis,
new bone formation as well as joint stiffness and/or fusion.1
Male patients are more commonly affected than female pa-
tients. The HLA-B27 major histocompatibility antigen is ex-
pressed in approximately 80%-95% of patients with AS,
however; the diagnosis is determined by clinical and radio-
graphic criteria, not solely upon a positive test.2
The most common presenting complaint of AS is low back
pain and stiffness, which is frequently worse in the morning
but improves with activity. Symptoms typically begin during
late adolescence and early adulthood. Sacroiliitis is a frequent
and consistent finding of AS. Other frequently involved sites
include the facet, costotransverse, and costovertebral joints
as well as the diskovertebral articulations. Respiratory func-
tion can be compromised because of limited chest expansion,
and patients may rely solely upon the diaphragm for breath-
ing. Less commonly, the hips and shoulders can be involved
in the disease process. Hip flexion contractures can occur,
causing the patient to flex the knees to maintain an erect

188 1040-7383/$-see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1053/j.semss.2011.04.009
Osteotomies for cervical kyphosis from AS
Figure 1 Photographs of a 70-year-old man with ankylosing spon-
dylitis, who presented with a progressive chin on chest deformity.
(Color version of figure is available online.)
posture. Several other organ systems can also be affected by
AS, such as the eyes, heart, gastrointestinal tract, and lungs.3
Spinal involvement causes much of the disability associ-
ated with AS. The pathologic process leads to the formation
of bony syndesmophytes across the disk spaces. The bone
appears to flow from one vertebra to the next, resulting in a
characteristic radiographic appearance referred to as a “bam-
boo spine.” Because the facet joints are frequently involved
early in the disease process, patients tend to flex the spine to
unload painful articulations. As a result, they develop pro-
gressive kyphosis throughout the spinal column. The verte-
brae of the spine ultimately fuse together, and the patient
becomes fixed in a forward flexed position, which necessi-
tates flexion of the hips and knees to maintain an erect pos-
ture. The spine also develops osteopenia or osteoporosis,
which predisposes the patient to progressive deformity
and/or fracture.4 A sudden increase in pain or the magnitude
of deformity should be considered a fracture until proven
otherwise.
Clinical Manifestations
of Cervical Deformity
Cervical kyphosis because of AS can be extremely disabling
to the patient. In addition to pain, rigid cervical deformity
can significantly interfere with activities of daily living. Pa-
tients can develop difficulty with forward gaze, eating or
swallowing, hygiene, and breathing. Ambulation becomes
increasing difficult because of a combination of factors, in-
cluding sagittal imbalance, stiffness and/or pain in the hips
and knees, as well as the inability to visualize the front of the
body. Frequent falls combined with low bone density can
189
result in fractures, which may lead to acute or rapidly pro-
gressive deformity. Furthermore, fracture of the anklyosed
spine may lead to an acute change in neurological status.
Although most patients with AS have normal neurological
function, cervical deformity may lead to myelopathy because
of stenosis or atlantoaxial subluxation. The occipitocervical
and atlanto-axial joints may become unstable because they
are often the only remaining mobile segments in the patient’s
spine. The instability is the result of increased shear forces
above the long, rigid lever arm created by the ankylosed
subaxial spine.5 Furthermore, patients with AS may develop
psychosocial distress because of persistent pain, altered ap-
pearance, and the inability to care for themselves.
Clinical and
Radiographic Evaluation
The evaluation of a patient with AS and fixed cervical kypho-
sis begins with a thorough history. It is essential to under-
stand the patient’s baseline level of function and disability.
This includes questioning the patient about breathing, swal-
lowing, eating, ability to perform personal hygiene and other
activities of daily living, ambulation, work status, as well as
extent of pain. One should also ask the patient about recent
trauma, the timing of deformity progression, and the onset of
pain. A rapid increase in the extent of deformity or the sud-
den worsening of pain may indicate a fracture, even in the
absence of trauma. The past surgical history is critical to
preoperative planning, especially when the patient has had
previous spinal procedures. A complete history of previous
cervical spine operations is an important part of proper pre-
operative planning. The physical examination begins with an
assessment of the patients overall posture and sagittal balance
as well as of the patient’s gait. Residual range of motion of the
neck and spine should be evaluated and considered. A thor-
ough neurologic examination must be performed, including
tests that assess for the presence of myelopathy. Finally, one
must assess the status of other involved joints, in particular
the hips and knees, as significant contractures may need to be
addressed before correcting the cervical deformity.
All patients being considered for a cervical osteotomy re-
quire a complete medical assessment before surgery. A full
understanding of the patient’s baseline level of respiratory
and gastrointestinal function is necessary before undertaking
a cervical osteotomy. It is critical to identify comorbid con-
ditions that place the patient at risk for postoperative com-
plications, including heart disease, diabetes, and smoking. In
some cases, ear, nose and throat evaluation may be beneficial.
Certain patients may benefit from preoperative tracheos-
tomy, especially if their respiratory status is markedly abnor-
mal.
Radiographic evaluation should start with plain x-rays of
the cervical spine, including anteroposterior, lateral, flexion,
and extension views. Standard cervical x-rays are used to
determine the magnitude of the deformity and the presence
of hardware from previous surgery. Flexion-extension views
can alert the surgeon to the existence of mobile segments and
190
Figure 2 Standing lateral radiograph of the aforementioned patient,
showing severe sagittal plane imbalance, with sweeping global ky-
phosis and angular kyphosis at the cervicothoracic junction.
indicate if the deformity has any flexibility. Furthermore, the
patient should have full-length spine films with the hips and
knees in maximal extension to assess overall sagittal and cor-
onal balance (Fig. 2). In addition, we obtain high-resolution
computed tomography (CT) scans on all patients who are
being considered for surgery, including coronal, sagittal, and
3-dimensional reconstructions. We have found the 3-dimen-
sional reconstructions to be invaluable for preoperative plan-
ning and determining the amount of needed correction. The
CT scan is also used to determine the extent of bony fusion
and to assess the bony anatomy in preparation for spinal
instrumentation. In this regard, we have found low resolu-
tion CT scan to be inadequate (Fig. 3). All patients also un-
dergo magnetic resonance imaging (MRI) so that the physi-
cian can assess the status of the neurologic elements.
Profound cervical kyphosis may preclude the patient from
obtaining a traditional, closed MRI as the tube cannot accom-
modate the deformity. In these cases, we order either an open
MRI or a CT myelogram.
Preoperative assessment of the extent of cervical deformity
and the amount of correction obtained has historically been
measured using the chin-brow angle. The value is based
upon the angle created by a vertical line and a line drawn
along the patient’s chin and brow. However, we have found it
easier to calculate the angle of deformity based upon the
sagittal cuts of the CT or MRI scan than upon plain radio-
graphs. After evaluation of these studies, we estimate the
A.L. Wollowick, M.P. Kelly, and K.D. Riew
degree of correction that is needed to realign the cervical
spine. We have not found the chin-brow angle to be useful in
severe deformities, especially those involving deformity in
multiple planes. If the patient has retained motion in the
neck, especially from the occiput to C2, our goal is to align
the posterior vertebral line of C2 with the anterior vertebral
line of C7. This achieves a balanced cervical posture, pro-
vided that the thoracolumbar spine is balanced. If the cervical
spine is completely ankylosed, we correct the deformity to a
minimally flexed position, usually between 10 and 20°. In
this position, the patient can still see the front of his or her
body, which improves the ability to ambulate and perform
activities of daily living. A fully erect posture may look better
to a layperson, but makes daily life more challenging for the
patient.
Indications for Surgery
The most frequent indication for correction of fixed cervical
kyphosis in patients with AS is unbearable deformity. In
these cases, the patient may complain of inability to ambu-
late, to perform personal hygiene, or to carry out basic activ-
ities of daily living. Likewise, debilitating pain because of
fixed flexion of the cervical spine may be an indication to
proceed with surgical correction. Additional indications for
surgery are significant difficulty with swallowing or eating,
respiratory compromise, or neurologic deterioration. Al-
though acute fracture may necessitate surgery because of in-
stability or rapidly progressive deformity, it is our preference
to allow fracture healing before surgery. In these instances,
the patient is placed in a halo-vest until the fracture is united,
at which time deformity correction can be performed.
Patients with AS often have kyphosis of the cervical as well
as the thoracolumbar spines. The question often arises as to
which deformity should be addressed first. The simple an-
swer is that one should start with the more severe deformity.
However, it may not be clear which deformity is the most
significant. One way to tell whether the cervical deformity
needs correcting is to examine the patient in a seated posi-
tion. If the patient’s neck alignment is acceptable in a seated
position, then the cervical deformity usually does not require
an osteotomy. By contrast, if the cervical deformity is obvious
in a seated position, then it is usually severe enough to war-
Figure 3 Midsagittal CT scan.
Osteotomies for cervical kyphosis from AS
rant surgical treatment. If the patient has significant dyspha-
gia or respiratory embarrassment because of cervical kypho-
sis, then the cervical spine needs urgent correction. If the
patient cannot stand erect without bending the hips and
knees, indicating a substantial thoracolumbar kyphosis, then
it is our preference that the lumbar osteotomy be performed
first, because it is safer and easier to position the patient for a
cervical procedure after the thoracolumbar correction has
been achieved.
Smith-Petersen Osteotomy
Osteotomy for kyphosis of the spine was first described by
Smith-Petersen in 1945.6 Subsequently, Mason et al7 re-
ported the first case of cervical osteotomy for fixed flexion
deformity. In 1958, Urist8 demonstrated that cervical osteot-
omy for AS could be successfully performed under sedation
and local anesthesia with the patient in a seated position. In
1972, Simmons9 published the first series of cervical osteot-
omy using the technique described by Urist. In each case, the
osteotomy was performed at the cervicothoracic junction.
This location was selected because of the large size of the
spinal canal at C7-T1, the mobility of the spinal cord and
eighth cervical nerves in this region, preservation of reason-
able hand function in the event of C8 nerve injury, and the
position of the vertebral artery in front of the transverse pro-
cess of C7.
The Smith-Petersen procedure begins with a laminectomy
of C6, C7, and T1. Next, a wide lateral decompression of the
C8 nerve roots is performed by removing both of C7-T1 facet
joints. Osteoclasis is then performed by the use of a halo with
the patient under conscious sedation. The correction is based
upon the creation of an opening wedge through the ankylo-
sed anterior column. As such, all 3 spinal columns are dis-
rupted during the Smith-Peterson osteotomy creating inher-
ent spinal instability. Arthrodesis is dependent upon the
posterior bony elements as the anterior column is length-
ened.
Simmons10 more recently reviewed the outcomes of 131
consecutive cases of cervical extension osteotomy. Over time,
the technique was modified to include a wider area of decom-
pression, including removal of most or all the C7 pedicles.
Although several authors have described the use of instru-
mentation to help maintain head position after cervical os-
teotomy, Simmons did not advocate the use of implants be-
cause of the extensive osteopenia found in patients with AS.
Even with instrumentation, he recommended a halo-vest to
add supplemental stability until the osteotomy site achieved
a solid fusion. Although the Simmons experience is the larg-
est in the literature, others have successfully modified the
technique of performing cervical extension osteotomy to in-
clude the use of modern anesthesia, neurological monitoring,
and instrumentation techniques. The first reports of success-
ful cervical extension osteotomy performed in this fashion
were published in the 1990s.11,12
Although some surgeons still perform cervical osteotomies
under local anesthesia, the use of general anesthesia with
spinal cord monitoring appears to be safe.13 The use of mod-
191
Figure 4 A patient with a severe chin-on-chest deformity positioned
on a well-padded Jackson frame. Notice the reinforced chest bolster
which is used to accommodate positioning of the cervical spine.
(Color version of figure is available online.)
ern instrumentation systems provides adequate fixation and
can eliminate the need for a postoperative halo vest.14 Finally,
pedicle subtraction procedures are being used more com-
monly because of increased stability at the osteotomy site.
PSO is performed by the creation of a closing wedge through
the vertebral body, which is more stable than the opening
wedge produced by the Smith-Petersen procedure. Further-
more, the anterior column remains intact and is not length-
ened, which further enhances the stability of the spine fol-
lowing the procedure. In the following sections, we will
discuss our technique for performing a cervical PSO.
Pedicle Subtraction Osteotomy
Anesthesia and Patient Positioning
Traditionally, osteotomies of the cervical spine for correction
of severe flexion deformity were performed with the patient
in the seated position and awake to provide immediate neu-
rologic feedback. Our preference, however, is to use general
anesthesia for all pedicle subtraction procedures. The use
of neurologic monitoring, including both somatosensory-
evoked potentials and motor-evoked potential techniques,
has made it safer to perform a cervical PSO under general
anesthesia. The use of the prone position for the patient is
more comfortable for the surgeon and improves his or her
ability to place instrumentation into the upper thoracic spine.
Anesthesia is administered by the use of an intravenous pro-
tocol (total intravenous anesthesia, ie, TIVA), and, if there is
any change in the monitoring signals, a wake-up test is per-
formed.
Prone patient positioning can be difficult because it is nec-
essary to accommodate both the cervical and other deformi-
ties. We have found it is easiest to place the patient on the
Jackson spinal frame equipped with a chest bolster, anterior
iliac crest pads, and a leg sling (Fig. 4). Because many patients
also have severe thoracic or thoracolumbar kyphosis, it is
necessary to place extra pillows and padding to support the
patient on the table. We are careful to position the patient as
far from the head of the table as possible to permit the use of
the operating microscope. In addition, it is necessary to ad-
just the table to the maximum amount of reverse Trendelen-
192 A.L. Wollowick, M.P. Kelly, and K.D. Riew

15 minutes, which reduces the risk of postoperative infec-

tion.
After the spine is completely exposed, the next step is to
place all the instrumentation. We place pedicle screws at C2
when the patient’s anatomy allows, but laminar screws can
also be used at this level. However, the use of C2 laminar
screws can complicate the placement of the rod and may
necessitate the use of cross-connectors. Lateral mass screws
are placed bilaterally at C3, C4, C5, and sometimes, C6.
Pedicle screws are placed bilaterally from T2 to T4, and
sometimes at T1. If a C6 screw is placed, then the T1 screw is

Figure 5 Gardner-Wells tongs are placed after induction of general

anesthesia. These are preferable to Mayfield tongs. (Color version of
figure is available online.)

burg. This permits the surgeon to work with as level a field as

possible and allows blood to pool in the legs and abdomen,
which can reduce the total amount of blood loss. The head is
secured using Gardner-Wells tongs with 15 lbs of weight
(Fig. 5). We have found tongs to be more efficient and ver-
satile than a Mayfield head clamp. Two ropes are attached to
the tongs: one with a vector in line with the deformity and a
second that pulls the head into an extended position (Fig. 6).
The weight is switched from the first to the second rope after
the osteotomy is completed, which helps with the deformity
correction.

Surgical Technique
In almost all cases, the PSO is performed at C7. A midline
incision is used to access the cervical and upper thoracic
spines. The proximal level of the exposure is based upon the
anticipated upper instrumented vertebra. We attempt to pre-
serve the occipital-cervical and atlanto-axial joints if reason-
able mobility remains. In these cases, we stop the fusion at
C2. If the cervical spine is completely ankylosed or if there is
only minimal residual motion at the Oc-C1 and C1-C2 joints,
we extend the construct to the skull because of the dense
bone found at the inion. Typically, the distal instrumented
level is either T3 or T4 to ensure that there are 6 or 8 points
of fixation distal to the level of the osteotomy.
Meticulous hemostasis is necessary to avoid significant
blood loss. By remaining directly in the midline during the
dissection, one can minimize the total blood loss for the
procedure. Although the lateral masses must be exposed in
their entirety, dissection further lateral will lead to excessive Figure 6 Bivector traction is applied through the Jackson table. The
bleeding and is unnecessary. Because of the care and time weights (15 lbs) are initially attached to rope A and pull traction in
spent controlling bleeding during the procedure, we have line with the deformity. After the osteotomy, the weights are moved
rarely had to transfuse patients who have undergone a cervi- to rope (B), which places an extension moment on the neck and
cal PSO. Furthermore, we copiously irrigate the wound every facilitates reduction. (Color version of figure is available online.)
Osteotomies for cervical kyphosis from AS 193

Figure 7 (A) The laminectomy is started with a high-speed bur. (B) Hemostasis is aided by cotton paddies. (Color
version of figure is available online.)

omitted because there is often not enough space for both inside both C7 pedicles. One must work cautiously to avoid
screws once the osteotomy is closed. Likewise, C6 remains violation of the pedicle walls. The bur is then passed through
uninstrumented if T1 pedicle screws are used. The choice of the pedicles into the vertebral body to begin the decancelliza-
which of these levels to instrument is dependent upon tion of C7 (Fig. 11).
whether the cephalad or caudad side of the osteotomy re- Once a cavity is created in the C7 vertebral body, fine
quires more fixation points. With modern instrumentation reverse-angle curettes and pituitary rongeurs can be used to
systems, especially those with an articulated or hinged rod, it remove the remaining pedicle walls (Fig. 12). The pedicles
is possible to use a single rod to connect the occiput or upper must be completely resected to prevent damage to the C7
cervical spine to the thoracic spine. This avoids the need for nerve roots during closure of the osteotomy site. Reverse-
connectors and allows the placement of hardware at every angle curettes and small round tamps are then used to create
level of the spine. To simplify the placement of the rods, it is a cavity in the posterior superior portion of the C7 vertebral
best to place the screws in as straight a line as possible. In so body (Fig. 13). The cancellous bone can either be removed or
doing, the surgeon can eliminate the need to bend the rod in pushed anteriorly. The decancellation is carried out as far
multiple planes. laterally as possible, including the lateral cortex of the body.
The osteotomy begins with a complete laminectomy of C7, The lateral cortex of the body is usually not much further
which is performed with a high-speed bur (Fig. 7). We prefer lateral than the lateral border of the pedicle. Therefore, as
to remove the lamina and spinous process of C7 as a single
unit for use as bone graft at the conclusion of the osteotomy
(Fig. 8). Next, the inferior half of the C6 lamina and the
superior half of the T1 lamina are resected. The spinous pro-
cesses of these vertebrae are left intact. Next, the lateral
masses of C7 are excised using a Leksell rongeur and the
high-speed bur (Fig. 9). The facets must be completely ex-
cised, including the caudal aspect of the inferior facet of C6
and the cranial aspect of the superior facet of T1. The T1
pedicles must be visualized to ensure that there is no residual
facet cranial to the pedicle. Any overhanging bone may com-
press the C8 root when the osteotomy site is closed. The C7
and C8 nerve roots should now be completely exposed and
visualized. The C7 pedicle remains between these 2 nerve
roots. The thecal sac and the 2 roots are protected with small
cottonoid paddies and retracted gently with Penfield #1, 2, Figure 8 The lamina of C7 is removed in one piece and saved for use
and 4 retractors (Fig. 10). The bur is used to remove the bone as local bone graft. (Color version of figure is available online.)
194
long as one removes cancellous bone from the body along the
lateral border of the pedicle, there is adequate bony removal
for closure of the osteotomy.
Finally, Woodson or angled-dural elevators are placed in
front of the posterior longitudinal ligament on either side of
the spinal canal (Fig. 14). The elevators are then used to push
the dorsal cortex into the previously created cavity. If an
adequate decancellization has been performed, the impac-
tion of the posterior cortex requires little force. If the dorsal
cortex of the C7 vertebral body does not break easily, then it
is necessary to remove more bone from inside the vertebral
body. Hemostasis is then obtained with thrombin-soaked gel
foam or a liquefied hemostatic collagen preparation.
The rod is then connected to the thoracic pedicle screws.
The rod either must be prebent to the desired angle of cor-
rection before placement or an articulated rod must be used
(Fig. 15). We prefer to use one of several commercially avail-
able hinged rods because they allow more flexibility and are
far easier to work with then a solid rod. The weight is
switched to the second rope, and the surgeon then pulls
Figure 9 The lateral masses of C7 are removed, first with the Leksell
rongeur (A), then with the high-speed bur (B). (Color version of
figure is available online.)
A.L. Wollowick, M.P. Kelly, and K.D. Riew
Figure 10 The dura and nerve roots are protected with Penfield
retractors and cotton paddies. This isolates the pedicle. (Color ver-
sion of figure is available online.)
gently on the Gardner-Wells tongs to extend the neck. As the
head is extended, the rod should engage the heads of the
previously placed cervical screws and/or occipital plate.
Locking caps are placed to maintain the position of the rod in
the heads of the screws (Fig. 16). If enough bone has been
removed, then little force is needed to perform the extension
maneuver. If one cannot easily extend the neck, then more
bone needs to be resected from the ventral portion of C7.
After extension of the neck, the C7 and 8 roots must be
examined for any signs of impingement. Removal of more
bone from the C6 inferior facet or the T1 superior facet may
be needed if there is any compression of the C7 and C8 roots.
Once the deformity is corrected and the hardware is secured
in position, neuromonitoring signals are checked multiple
times to ensure that no change has occurred. If there is any
change in the neurologic monitoring data, then the amount
of correction can be reduced and a wake-up test is per-
formed. X-rays are then performed to determine the amount
of correction obtained and the overall alignment of the cer-
vical spine. We also use the x-rays to confirm the position of
all the implanted hardware and to ensure the integrity of the
anterior column. A single-level PSO can result in a correction
Figure 11 Decancellation of the pedicle is started with the high speed
bur. The bur is used to enter the pedicle. (Color version of figure is
available online.)
Osteotomies for cervical kyphosis from AS 195

Figure 12 The decancellation of the pedicle proceeds with a curette.

(Color version of figure is available online.)

of approximately 45-65°. With greater levels of correction, it

is not uncommon for the anterior column to break and gap
open. As long as there are at least 6 points of pedicle screw
fixation below the osteotomy and 8 points of fixation above
it, the spine should retain adequate stability. One can usually
obtain corrections of up to 45° while keeping the anterior
column intact.
If the anterior column has wedged open or if we are oper-
ating on a patient with an acute fracture, then we perform an
anterior approach immediately after closure of the posterior
wound. We will also add anterior hardware, in the absence of Figure 14 (A) A Woodson elevator is used to impact the remaining
anterior instability, if the strength of the posterior instrumen- posterior body wall into the void that has been created. (B) The
tation is insufficient. In these cases, we place an anterior Woodson is used on both sides of the body, to connect the osteot-
cervical plate with 2 or more screws above and below the omy beneath the spinal cord. (Color version of figure is available
level of the osteotomy to act as an anterior tension band, with online.)
or without bone graft depending upon the size of the gap.
This eliminates the need for a postoperative halo vest and
provides added rigidity to the construct. arthrodesis, we use local autograft obtained from the bony
resection at C6, C7, and T1. We begin by splitting the spi-
Bone Grafting, Wound Closure, nous process of C7 in the sagittal plane. This is placed along
the sides of the decorticated C6 and T1 spinous processes
and Postoperative Management and cabled into position. If a gap remains between the C6
Typically, the osteotomy site will obtain a solid fusion with- lateral mass and T1, a spinous process from the upper tho-
out supplemental bone grafting, but this step requires a min- racic spine can provide adequate bone to fill the defect. Fi-
imal gap between the remaining bone surfaces. To ensure

Figure 15 An articulated rod is placed in the screw heads. Minimal

Figure 13 A void is created within the body and the pedicle with a contouring is needed if the screws are placed with the heads in line.
small tamp. (Color version of figure is available online.) (Color version of figure is available online.)
196 A.L. Wollowick, M.P. Kelly, and K.D. Riew

200 posterior cervical procedures of all kinds, including os-

teotomies.
In most cases, the patient can be extubated immediately
after the PSO. This may not be possible in patients with
severe preoperative respiratory compromise. Our typical op-
erative time to perform a cervical PSO is between 3 and 5
hours. Because of the extensive instrumentation that is used,
the patients are only immobilized in a hard cervical collar
postoperatively. We have not needed to use a halo-vest in any
patient who has undergone a cervical pedicle subtraction
procedure. Ambulation is started on the first postoperative
day, and most patients are discharged on the first or second
postoperative day.
Figure 16 The head is extended (with the weights switched to Rope
B as seen in Fig. 6) and the osteotomy is closed. The articulating rods Risks/Complications
are fixed in this position. (Color version of figure is available online.)
Both the Smith-Petersen osteotomy and the PSO in the cer-
vical spine have many potential complications. The neuro-
nally, the area between the remaining C6 and T1 laminae is logical risks are high. Instances of paralysis as well as incom-
covered with the rest of the local bone, including the bone plete neurological deficits have been reported following
dust created by the use of the high-speed bur. We have not cervical extension osteotomies.13 In most cases reported in
had to use any additional bone graft substitutes or extenders the literature, the neurologic deficits that develop after cervi-
for a cervical PSO. cal extension osteotomies are transient. C8 nerve root palsy is
The posterior wound closure requires as much attention as the most commonly reported neurologic complication. How-
the exposure and the osteotomy itself. Poor closure can lead ever, permanent paralysis, incomplete spinal cord injury, and
to several complications, including the formation of hemato- never root palsy have also been reported. Most patients with
mas, postoperative infection, wound dehiscence, and poor AS undergoing a cervical extension osteotomy have either
cosmesis. We close the posterior soft tissues in multiple lay- osteopenia or osteoporosis, which can lead to either hard-
ers to reconstruct the normal anatomy to the best extent ware failure or pseudoarthrosis. Likewise, intraoperative
possible. When performing any of the cervical extension os- fracture at either the operative or a non-operative level can
teotomies, redundant skin folds are created by the procedure. occur during deformity correction. It is essential to scrutinize
In most cases, the appearance of the skin will normalize over intraoperative imaging studies to ensure that a new fracture
several months (Fig. 17). However, if the skin redundancy has not developed while the patient was under anesthesia.
makes closure exceedingly difficult, then we recommend re-
moving an ellipse of full-thickness skin to lessen or eliminate
the excess tissue. Extra care must be taken at the corners of
the wound to prevent necrosis and wound dehiscence. We
typically use 3 drains, including one along the posterior cer-
vical spine, one in the intermediate muscle layer below the
fascia, and another in the subcutaneous layer.
Hemostasis is verified as each layer is closed; bleeding that
is created by suture passage is coagulated before tying the
knot. In addition, we place a large thrombin-soaked gel foam
in the wound before closure, which reduces the amount of
bleeding created by suture passage. After each layer is closed,
we apply strong manual compression to the wound for 30-45
seconds to promote hemostasis. With meticulous closure
technique, the amount of fluid collected in the drains is quite
minimal. In most cases, the drains are removed within the
first 24 hours after surgery. Each drain is removed when ⬍30
mL of fluid is collected in an 8-hour shift. We continue ad-
ministering perioperative antibiotics until all the drains have
been removed. Our infection rate has been extremely low
despite the extensive nature of these procedures because of
the care taken during wound closure. For the past several
years, we have also sprinkled 500 mg of vancomycin powder
in the wound before closure. Since we began adding vanco- Figure 17 A cosmetically pleasing, well-healed posterior wound.
mycin to the wounds, we have had no infections in more than (Color version of figure is available online.)
Osteotomies for cervical kyphosis from AS
Figure 18 Postoperative anteroposterior (A) and lateral (B) radiographs of the patient seen in Fig. 1. Note: here, excessive
anterior column gapping was noted after the extension osteotomy. Thus, an anterior fusion with allograft and plate was
performed to obtain stability and circumferential fusion.
There is also a risk of injury to the vertebral artery, but it is
minimized by performing the procedure at C7 and appropri-
ate intraoperative awareness of the local vascular anatomy.
The posterior approach can be complicated by wound heal-
ing problems, such as infection and wound dehiscence. In
most cases, these soft-tissue concerns can be alleviated by
Figure 19 Lateral clinical photograph of the patient seen in Fig. 1.
Notice the slightly flexed position. This allows patients to see both
ahead and the ground below them. (Color version of figure is avail-
able online.)
197
appropriate care taken during the exposure and wound clo-
sure. Intraoperative consultation from plastic surgery may be
prudent in cases of extremely difficult closure or when the
patient has had previous surgery.
Conclusions
AS can be a debilitating disorder that can impact all aspects of
the patient’s life. Among the most disabling consequences of
AS is severe, fixed cervical kyphosis. A chin-on-chest defor-
mity can create difficulty with activities of daily living, swal-
lowing, and breathing as well as neurologic deterioration.
Both the Smith-Petersen osteotomy and the cervical PSO can
be used to treat patients with severe cervical kyphosis. These
techniques are technically challenging and carry high risks.
Although the overall experience in the literature is far greater
with the Smith-Petersen approach, PSO is gaining favor be-
cause of the increased biomechanical stability of the con-
struct (Fig. 18). The use of general anesthesia, neurological
monitoring, and modern instrumentation has made perform-
ing both of these operations easier on the surgeon and safer
for the patient. Regardless of the technique chosen, when
safely performed, cervical extension osteotomy can result in
extremely high patient and surgeon satisfaction (Fig. 19).
Disclosure
The authors reported no proprietary or commercial inter-
est in any product mentioned or concept discussed in this
article.
198
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