European Spine Journal

, Volume 22, Issue 4, pp 819–832 | Cite as

Non-instrumented correction of cervicothoracic kyphosis in ankylosing spondylitis: a critical analysis on the results of open-wedge osteotomy C7-T1 with gradual Halo-Thoracic-Cast based correction

  • Heiko Koller
  • Oliver Meier
  • Juliane Zenner
  • Michael Mayer
  • Wolfgang Hitzl
Original Article



With progression of cervicothoracic kyphosis (CTK), ankylosing spondylitis (AS) patients suffer functional disability. Surgical correction still poses neurologic risks, while evidence of an ideal technique preventing its complications is weak.

Materials and methods

We report our results with non-instrumented correction in perspective of a review of literature, serving as an important historical control. Database review identified 18 AS patients with CTK correction. After application of a Halo-Thoracic-Cast (HTC) patients underwent posterior non-instrumented open-wedge osteotomy at C7/T1 and osteotomy closure by threaded HTC-rod adjustments. Postoperative gradual HTC correction was continued for 2–4 weeks. Patients were invited for follow-up and medical charts were reviewed for demographics, surgical details, complications and outcomes. The patients’ preoperative, postoperative, before HTC removal and follow-up photographs were analyzed for the Chin-Brow-Vertical-Angle (CBVA), radiographs for the CTK angle.


Patients’ age was 50 ± 11 years, follow-up was 37 ± 47 months and CBVA correction was 25° ± 9° (p < 0.000001). The final radiographic correction at follow-up was 20° ± 11° (p = 0.00002). At the latest follow-up, three patients judged their outcome as excellent, nine good, three moderate and one poor. Upon invitation, seven patients appeared with follow-up averaging 87 months. Neck-pain disability index was 8 ± 14 %. Two patients died, three were lost, one had revision elsewhere and five just had a routine follow-up. Six patients sustained a minor and ten a major complication. Revisions were indicated in five patients including infection, C8-radiculopathy and neurologic events by translation at the osteotomy. A total of 44 % of patients showed translation at the osteotomy indicating acute surgery with instrumentation twice after osteotomy closure, three patients had a revision posterior decompression and instrumented fusion for sequels related to translation.


With the non-instrumented HTC-based technique, average CBVA correction of 25° was achieved and all patients were ambulatory at follow-up. However, regarding translation at the osteotomy, loss of correction, morbidity of the HTC and lack of control at the osteotomy instrumentation-based correction and instrumented fusion seem to be preferable.


Cervical kyphosis Ankylosing spondylitis Open-wedge osteotomy Halo-Thoracic-Cast Halo-based correction Rigid kyphosis 


Conflict of interest

There are no conflict of interest by the authors regarding the manuscript.


  1. 1.
    O’Shaughnessy BA, Liu JC, Hsieh PC, Koski TR, Ganju A, Ondra SL (2008) Surgical treatment of fixed cervical kyphosis with myelopathy. Spine 33:771–778PubMedCrossRefGoogle Scholar
  2. 2.
    Mason C, Cozen L, Adelstein L (1953) Surgical correction of flexion deformity of the cervical spine. Calif Med 79:244PubMedGoogle Scholar
  3. 3.
    Urist MR (1958) Osteotomy of the cervical spine. J Bone Joint Surg Am 40:833–843PubMedGoogle Scholar
  4. 4.
    Etame AB, Thoi KD, Wang AC, LaMarca F, Park P (2008) Surgical management of symptomatic cervical or cervicothoracic kyphosis due to ankylosing spondylitis. Spine 33:E559–E564PubMedCrossRefGoogle Scholar
  5. 5.
    Hoh DJ, Khoueir P, Wang MY (2008) Management of cervical deformity in ankylosing spondylitis. Neurosurg Focus 24(1):E9Google Scholar
  6. 6.
    Mehdian SMH, Freeman BJC, Licina P (1999) Cervical osteotomy for ankylosing spondylitis: an innovative variation on an existing technique. Eur Spine J 8:505–509PubMedCrossRefGoogle Scholar
  7. 7.
    Mehdian SMH, Arun R (2011) A safe controlled instrumented reduction technique for cervical osteotomy in ankylosing spondylitis. Spine 36:715–720PubMedCrossRefGoogle Scholar
  8. 8.
    Chavanne A, Pettigrew DB, Holtz JR, Dollin D, Kuntz C (2011) Spinal cord intramedullary pressure in cervical kyphotic deformity. Spine 36:1619–1626PubMedCrossRefGoogle Scholar
  9. 9.
    Belanger TA, Milam RA, Roh JS, Bohlman HH (2005) Cervicothoracic extension osteotomy for chin-on-chest deformity in ankylosing spondylitis. J Bone Joint Surg 87(A):1732–1738PubMedCrossRefGoogle Scholar
  10. 10.
    Chin KR, Ahn J (2007) Controlled cervical extension osteotomy for ankylosing spondylitis utilizing the Jackson operating table. Spine 32:1926–1929PubMedCrossRefGoogle Scholar
  11. 11.
    Khoueir P, Hoh DJ, Wang MY (2008) Use of hinged rods for controlled osteoclastic correction of a fixed cervical kyphotic deformity in ankylosing spondylitis. J Neurosurg Spine 8:579–583PubMedCrossRefGoogle Scholar
  12. 12.
    McMaster MJ (1997) Osteotomy of the cervical spine in ankylosing spondylitis. J Bone Joint Surg 79(B):197–203CrossRefGoogle Scholar
  13. 13.
    Mummaneni PV, Mummaneni VP, Haid RW, Rodts GE, Sasso RC (2003) Cervical osteotomy for the correction of chin-on-chest deformity in ankylosing spondylitis. Neurosurg Focus 14(1):e9PubMedCrossRefGoogle Scholar
  14. 14.
    Tokala DP, Lam KS, Freeman BJC, Wenn JK (2006) C7 decancellation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis. Eur Spine J 16:1471–1478CrossRefGoogle Scholar
  15. 15.
    Samudrala S, Vaynman S, Thiayananthan T, Ghostine S, Bergey DL, Anand N, Pashman RS, Johnson JP (2010) Cervicothoracic junction kyphosis: surgical reconstruction with pedicle subtraction osteotomy and Smith-Peterson osteotomy. J Neurosurg Spine 13:695–706PubMedCrossRefGoogle Scholar
  16. 16.
    Halpern EM, Bacon SA, Kitagawa T, Lewis SJ (2010) Posterior transdiscal three-column shortening in the surgical treatment of vertebral discitis/osteomyelitis with collapse. Spine 35:1316–1322PubMedCrossRefGoogle Scholar
  17. 17.
    Simmons ED, DiStefano RJ, Zheng Y, Simmons EH (2006) Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes. Spine 31:3006–3012PubMedCrossRefGoogle Scholar
  18. 18.
    Simmons EH (1972) The surgical correction of flexion deformity of the cervical spine in ankylosing spondylitis. Clin Orthop Rel Res 86:132–143CrossRefGoogle Scholar
  19. 19.
    Hehne HJ, Zielke K (1987) Die zervikale Aufrichtungsosteotomie nach Mason und Urist bei Spondylarthritis ankylopoetica (german). Akt Rheumatol 12:126–130CrossRefGoogle Scholar
  20. 20.
    Deviren V, Scheer JK, Ames CP (2011) Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases. J Neurosurg Spine 15:174–181PubMedCrossRefGoogle Scholar
  21. 21.
    Glassmann SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG (2007) The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine 32:2764–2770CrossRefGoogle Scholar
  22. 22.
    Suk K-S, Kim K-T, Lee S-H, Kim J-M (2003) Significance of chin brow vertical angle in correction of kyphotic deformity of ankylosing spondylitis patients. Spine 28:2001–2005PubMedCrossRefGoogle Scholar
  23. 23.
    Harrison DE, Harrison DD, Cailliet R, Troyanovic SJ, Janik TJ, Holland B (2000) Cobb method or Harrison posterior tangent method. Which to chose for lateral cervical radiographic analysis. Spine 25:2072–2078PubMedCrossRefGoogle Scholar
  24. 24.
    Langeloo DD, Journee HL, Pavlov PW, de Kleuver M (2006) Cervical osteotomy in ankylosing spondylitis: evaluation of new developments. Eur Spine J 15:493–500PubMedCrossRefGoogle Scholar
  25. 25.
    Bouchard JA, Feibel RJ (2002) Gradual multiplanar cervical osteotomy to correct kyphotic ankylosing spondylitic deformities. Can J Surg 45:215–218PubMedGoogle Scholar
  26. 26.
    Wang Y, Lenke LG (2011) Vertebral column decancellation for the management of sharp angular deformity. Eur Spine J 20:1703–1710PubMedCrossRefGoogle Scholar
  27. 27.
    Kawahura H, Tomita K (2005) Influence of acute shortening on the spinal cord: an experimental study. Spine 30:613–620CrossRefGoogle Scholar
  28. 28.
    Lenke LG, O’Leary PT, Bridwell KH, Sides BA, Koester LA, Blanke KM (2009) Posterior vertebral column resection for severe pediatric deformity: minimum two-year follow-up of thirty-five consecutive patients. Spine 34:2213–2221PubMedCrossRefGoogle Scholar
  29. 29.
    Pavlov PW (2009) Correction and stabilisation in ankylosing spondylitis of the cervicothoracic spine. Eur Spine J 18:1243–1244PubMedCrossRefGoogle Scholar
  30. 30.
    Hojo Y, Ito M, Abumi K, Kotani Y, Sudo H, Takahata M, Minami A (2010) A late neurological complication following posterior correction of severe kyphosis. Eur Spine J 20:890–898PubMedCrossRefGoogle Scholar
  31. 31.
    Herbert JJ (1959) Vertebral osteotomy for kyphosis, especially in Marie–Strümpell arthritis. J Bone Joint Surg 41(A):291–302PubMedGoogle Scholar
  32. 32.
    Graziano GP, Hensiner R, Patel CK (2001) The use of traction methods to correct severe cervical deformity in rheumatoid arthritis patients. A report of five cases. Spine 26:1076–1081PubMedCrossRefGoogle Scholar
  33. 33.
    Schneider PS, Bouchard J, Moghadam K, Swamy G (2010) Acute cervical fractures in ankylosing spondylitis. Spine 35:E248–E252PubMedCrossRefGoogle Scholar
  34. 34.
    Saeed MU, Dacuycuy MAC, Kennedy DJ (2007) Halo pin insertion-associated brain abscess. Case report and review of literature. Spine 32:E271–E274PubMedCrossRefGoogle Scholar
  35. 35.
    Limpaphayom N, Skaggs DL, McComb G, Krieger M, Tolo VT (2007) Complications of Halo use in children: 42nd annual meeting of the SRS, Edinburgh/ScotlandGoogle Scholar
  36. 36.
    Law AW (1962) Osteotomy of the Spine. Instructional Course Lecture AAOS 44(A):1199–1206Google Scholar
  37. 37.
    El Shagir H, Boehm H (2002) Surgical options in the treatment of the spinal disorders in ankylosing spondylitis. Clin Exp Rheumatol 20:S101–S105Google Scholar
  38. 38.
    Deviren V, Scheer JK, Ames CP (2010) Pedicle subtration osteotomy for cervicothoracic kyphosis. Techniques and report of 10 cases: 38th annual meeting of CSRS-A, CharlotteGoogle Scholar
  39. 39.
    Scheer JK, Tang JA, Deviren V, Buckley J, Pekmezci M, McClellan RT, Ames CP (2010) Biomechanical analysis of osteotomy type (OWO, CWO) and rod diameter for treatment of cervicothoracic kyphosis: IMAST 2010, TorontoGoogle Scholar
  40. 40.
    Mummaneni PV, Dhall SS, Rodts GE, Haid RW (2008) Circumferential fusion for cervical kyphotic deformity. J Neurosurg Spine 9:515–521PubMedCrossRefGoogle Scholar
  41. 41.
    Shimizu K, Matsushita M, Fujibayashi S, Toguchida J, Ido K, Nakamura T (1996) Correction of kyphotic deformity of the cervical spine in ankylosing spondylitis using general anesthesia and internal fixation. J Spinal Disord 9:540–543PubMedCrossRefGoogle Scholar
  42. 42.
    Koller H, Zenner J, Hitzl W, Ferraris L, Resch H, Tauber M, Auffarth A, Lederer S, Mayer M (2009) In vivo analysis of atlantoaxial motion in individuals immobilized with the halo thoracic vest or Philadelphia collar. Spine 34:670–679PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Heiko Koller
    • 1
  • Oliver Meier
    • 1
  • Juliane Zenner
    • 1
  • Michael Mayer
    • 1
  • Wolfgang Hitzl
    • 2
  1. 1.German Scoliosis CenterWerner Wicker ClinicBad WildungenGermany
  2. 2.Research Office, BiostatisticsParacelsus Medical UniversitySalzburgAustria

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