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Chin-on-chest deformity

 

Spine

Anatomy

 

 

 

 

 

Post-Laminectomy Kyphosis

Before correction

After correction

 

 

Cervical Corpectomy

 

Spine

Posterior Fusion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cervical Kyphosis

 

Introduction

When viewed from the side, the normal cervical spine curves slightly inward. This inward curve is called lordosis. Kyphosis is a term used to describe a type of abnormal curve in the spine. A kyphotic curve looks like the letter "C" with the opening of the C pointing towards the front. This type of curve is the opposite of a normal lordotic curve, which has the opening facing towards the back. The larger the abnormal curve, the more serious the problem. Several different conditions can lead to an excessive kyphosis, also known as chin-on-chest deformity.

Learn about cervical kyphosis including

  • what causes cervical kyphosis
  • what problems may be caused by cervical kyphosis
  • how surgery is used to treat the condition

 

Anatomy

In order to understand your symptoms and treatment choices, it is helpful to start with a basic understanding of the anatomy of the spine. This includes becoming familiar with the various parts that make up the neck and how they work together.

Learn more about the anatomy of the cervical spine.

As described earlier, the cervical spine normally has a lordosis, or inward curvature. Kyphosis is an abnormal condition in the neck in which the normal inward curve reverses. This causes an abnormal forward curve in the cervical spine.

The stability of the cervical spine and its ability to stay in the lordotic position depends on other parts of the spine. The vertebral bodies need to be strong enough to support the head and keep the normal shape of the spine. The facet joints, ligaments, and soft tissues in the back of the neck and back must be strong. And the muscles in the back must be able to resist the effect of gravity pulling the head forward. If there is damage to any of these three areas, a kyphotic deformity can develop, and the weight of the head can cause reversal of the normal curvature of the spine.

Causes

This condition has several possible causes and can develop in both children and adults.

Iatrogenic Causes

Kyphosis can occur for iatrogenic reasons. "Iatrogenic" means that the problem happened from the effects of a medical treatment, such as surgery. Kyphosis can happen after laminectomy surgery. This procedure is done to relieve pressure on the spinal cord or spinal nerves. During the procedure, the lamina bone that covers the spinal canal is removed. Sometimes part or all of the facet joints are also removed during the procedure. This can cause looseness between the problem verterbrae. When this happens, the spine may begin to tilt forward.

Kyphosis may also happen after cervical fusion surgery. In this case, the spine will begin to "bend" over the topmost part of the fusion. The forward tilt causes an imbalance that can lead to kyphosis. Similar problems can also arise if the fusion fails to heal properly (pseudarthrosis). Even when a fusion heals normally, kyphosis can occur if the vertebrae heal with improper alignment.

 

Example: 48 year old female who had 6 prior failed operations including anterior fusions as well as laminectomies presented with progressive weakness, difficulty walking and paralysis in her left arm.

She severe and constant neck pain.

 

She underwent Mutilevel corpectomies as well as posterior instrumentation with significant pain relief and neurologic recovery.

 

 

Degenerative Disc Disease

Degeneration of the intervertebral disc can lead to kyphosis in the neck. In older adults, the wear and tear of aging can cause the discs to collapse. This may cause the head to tilt forward, making the neck bend forward too. This process may steadily get worse over many years. The weight of the head causes the unbalanced forces to push the neck further and further forward. This slowly leads to a loss of the normal curve and may end with a cervical kyphosis. Learn more about degenerative disc disease.

Example: 69 year old male presented with severe neck pain, inability to lift his head up and gait imbalance.  On examination, he was found to have chin-on-chest deformity.  He underwent a multilevel corpectomy with anterior and posterior reconstruction which restored his alignment and horizontal gaze.  He is pain free and neurologically intact.

 

Congenital Defect

Cervical kyphosis can be congenital, which means that you are born with it. A person born with some sort of defect, such as incomplete formation of part of the spine, may end up with an increasing kyphosis in the neck. Congenital kyphosis usually leads to a growth disturbance of the vertebrae. Instead of growing normally, the vertebrae grow into a triangular-shape with the thin end pointing forward. Because the vertebrae are stacked on top of each other, the triangle shape causes the spine to have a forward curvature. When a child has congenital kyphosis, there are generally additional birth defects in other areas of the body, most commonly of the kidneys and urinary system.

Trauma

Cervical kyphosis can occur as the result of an injury to the neck. Vertebral compression fractures cause the vertebral body to collapse into the shape of a wedge. This causes the section of spine to tip forward, and the resulting imbalance leads to a loss of the normal curvature of the neck. Other injuries that damage the ligaments along the back of the cervical spine can also cause kyphosis. If the kyphosis gets bad enough, it can narrow the spinal canal and put pressure on the spinal cord (spinal stenosis).

Example:  54 year old nurse who was invilved in a car accident presented with persistant neck pain and kyphosis six months later. She had suffered fron ligamentous injury which was not appreciated in the intial x-rays done in the emergency room.  New x-rays, CT anf MRI showed severe kyphotic deformity and post-tramatic grade 4 spondylolisthesis.

She was placed in traction for a week and subsequently underwent anterior and posterior reconstruction.  She had full neurologic recivery and is pain free.

 

Other Causes

Other less common causes of cervical kyphosis include infections or tumors in the spine, systemic (whole body) diseases that affect the spine such as ankylosing spondylitis and radiation therapy for cancer in the neck. Children especially who have had radiation therapy to the neck may have altered growth in the cervical vertebrae, leading to future problems with kyphosis.

Symptoms

The symptoms and severity of kyphosis vary. Symptoms range from minor changes in the shape of your spine, to severe deformity, neurologic deficits, and chronic pain. Neck movement may become limited, making it difficult to turn the neck fully or to look up for very long. The abnormal forward curvature can eventually appear unattractive. Neck pain may be present, especially if the kyphosis is caused by degenerative changes.

If the kyphosis is severe, pressure can occur on the spinal nerve roots or spinal cord. This can cause weakness in the arms or legs, loss of grip strength, or difficulty walking due to spasticity in the legs. Bowel or bladder control may be lost. In extremely severe cases that are left untreated, paralysis from the neck down may even result.

With a kyphotic deformity, the spinal cord may be stretched where the spine bends forward. The spinal cord is the body's connection to the brain. When it is damaged or compressed, the body loses some of its ability to function properly. If pressure builds up on the spinal cord, it can cause myelopathy. Myelopathy may impair normal walking, hand and finger use, and bowel and bladder function. Doctors take these symptoms very seriously because severe myelopathy that is not treated may lead to permanent nerve damage. Pressure on the spinal cord can eventually lead to quadriplegia, paralysis of all four limbs.

Diagnosis

Finding the cause of your neck problem begins with a complete history and physical exam. Various diagnostic tests may be ordered to help your doctor determine exactly what is causing your symptoms. The most common tests used to diagnose cervical kyphosis are X-ray and MRI.

Treatment Options

The typical treatment for congenital kyphosis is surgery. Early surgical intervention usually produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality. Conservative treatments do not have much success at correcting this type of kyphosis. When surgery is not done, it is critical that the condition is observed and that close medical follow-up is done, including X-rays and MRI scans. This is to make sure the kyphosis isn't worsening to the point it causes more serious problems.

Conservative Treatment

Treatment for cervical kyphosis depends largely on whether there is pressure on the spinal cord. If there is, surgery may be suggested. If the cervical kyphosis is primarily causing pain and concern about your appearance, then the doctor may consider trying to control the pain and deformity with a neck brace for a short period of time, pain medications, and a physical therapy program.

Physical Therapy

Your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

Exercise has not proven helpful for changing the kyphotic curve in the neck. However, it can be helpful in providing pain relief. Therapy sessions may be scheduled two to three times each week for up to six weeks.

The goals of physical therapy are to help you

  • learn correct posture and body movements to counteract the effects of kyphosis
  • maintain appropriate activity levels
  • maximize your neck range of motion and strength
  • learn ways to manage your condition

Learn more about spinal rehabilitation.

Surgical Treatment

If the kyphosis is flexible, the decision to go ahead with surgery will be based on the progression of the curve and the amount of pain it causes. If the curve and pain are minor, surgery may not be recommended-even if the deformity looks unattractive. If the deformity is severe and the pain is chronic, surgery may be a good option.

Surgery is usually not recommended when the deformity is fixed (inflexible but not worsening) and if there are no problems with the nerves or spinal cord. If a fixed deformity is accompanied by neurological problems from pressure on the spinal cord, the need for surgery is greater. Surgical correction is the most difficult type of treatment for cervical kyphosis.

Surgery to treat cervical kyphosis usually involves spinal fusion combined with segmental instrumentation. This means that some type of metal (titanium) plate or rod is used to hold the spine in the proper alignment to straighten it. Surgery may require two procedures done during the same operation. First, surgery to the front of the spine  (anterior) is done to relieve the pressure on the spinal cord. This is done by multilevel disctomy or by corpectomy.  The second procedure is done through the back (posterior) to fuse the spine and prevent the kyphosis from returning.

Example:   41 year old female with progressive neck pain and bilateral arm pain refractory to medications, injections and physical therapy.    X-ray and MRI revealed degeneration of C5-6 and C6-7 with impingment of the nerve roots and early degenerative kyphosis.  She underwent a two level anterior fusion and instrumentation with complete pain relief.

If the kyphosis is due to ankylosing spondylitis (AS), the connection between the cervical and thoracic spine is the problem area. This type of cervical kyphosis is usually a fixed deformity. In AS the discs between each vertebra of the entire spine calcify and fuse the bones of the spine together.  If there is a cervical kyphosis after AS fuses the spine, the surgeon may need to do an osteotomy of the fused spine. "Osteo" means bone, and "otomy" means cut. This procedure involves cutting the front of the spinal column so the surgeon can straighten the spine. The spinal cord is not cut-only the bones of the vertebrae in the front of the spinal column.


 

           

 




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