Cervical Spine Deformity

Indications, Considerations, and Surgical Outcomes

Samuel K. Cho, MD; Scott Safir, MD; Joseph M. Lombardi, MD; Jun S. Kim, MD


J Am Acad Orthop Surg. 2019;27(12):e555-e567. 

In This Article

Clinical Presentation and Indications

Initial evaluation of the patient should be tailored based on the suspected etiology of their deformity. Patients with AS often exhibit chronic deformity that is gradually and progressively debilitating. Alternatively, in the setting of trauma, they can also exhibit acute deformity secondary to fracture, with sudden decompensation in posture and evidence of neurologic deficit. Patients with cervical deformity and evidence of ankylosis on imaging with sudden pain should be considered to have a fracture until proven otherwise.

Examination of patients with AS should comprise of the patient standing upright with the hips fully extended and in the seated and supine positions. Patients with cervical deformity often exhibit persistent cervical flexion despite lying flat. The rigidity of the deformity can be often assessed by having the patient suspend his/her head in air when supine, the so-called head suspension test (Figure 6). Patients can also exhibit a chin-on-chest deformity that is characteristic of AS.

Figure 6.

A patient whose head is completely suspended in air because of rigid cervical kyphosis (head suspension test).

Iatrogenic deformities are unique in their presentation, and each requires their own corrective approach depending on the plane of deformity (sagittal, coronal, or both), the location of the fusion mass and instrumentation (anterior, posterior, or both), bone quality, soft-tissue quality, and the presence or absence of infection. In addition, patients with high to mid-cervical deformity may not present with an obvious abnormality on visual inspection (Figure 2). By contrast, those with cervicothoracic deformity often have a kyphotic appearance with difficulty raising the head and pain, similar to those suffering from flatback syndrome in the TLS (Figure 3). Revisions, especially in the setting of complex cervical deformity, require the utmost attention to detail to minimize complications.

The indications for corrective surgery in the setting of AS are intolerable deformity, neurologic deficit, airway compromise, esophageal dysmotility, and instability associated with fracture. The indications for surgery in the setting of iatrogenic deformity include intolerable posture, neurologic deficit, and intractable pain.