PMC6698528_01
Preoperative images. (A) Sagittal T2-weighted MRI shows multilevel cervical cord compression. (B) X-ray shows cervical lordotic alignment (C2-7 angle, 30 ), but the loading axis of the head is anterior (CGH-C7 SVA, 53 mm), which means that there was cervical sagittal imbalance. (C) Standing lateral X-ray shows marked thoracic kyphosis (Th5-Th12, 58 ). As a compensation, there is hyperlordosis in the cervical and lumbar spine.
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Magnetic resonance imaging showed multilevel spinal cord compression (Fig. 1A). Hydroxyapatite spacers were placed between the split laminae and fixed with non-absorbable sutures to maintain an enlarged spinal canal (Fig. 1B).
Images after first operation (cervical laminoplasty from C3 to C7). (A) X-ray at 10 months shows development of a cervical kyphotic alignment change combined with cervical disc degeneration. The loading axis of the head is shifted more anteriorly than shown preoperatively (CGH-C7 SVA, 75 mm). (B) Sagittal T2-weighted MRI shows recurrence of multilevel cervical cord compression despite the LAMP operation. (C) Photograph shows anterior shift of the head that demands sufficient power of the neck extensors to raise the head.
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The 10 month postoperative images showed a focal cervical kyphotic deformity causing anterior shift of the head (Fig. 2A) and recurrence of spinal cord compression (Fig. 2B).
Images after second operation (anterior decompression and fusion from C3 to C7). (A) Sagittal reconstruction CT just after anterior fusion. (B) Standing lateral X-ray at 13 months shows recurrence of cervical kyphosis and dislodgement of the anterior plate.
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Eighteen months after LAMP, her C-JOA score had decreased to 8 points, and she underwent a second operation, anterior cervical decompression and fusion (Fig. 3A). Nevertheless, cervical sagittal imbalance and dropped head were further progressed (Fig. 3B).
(A) Images after third operation (posterior fusion with C2 to Th5). X-ray just after posterior fusion. (B) Standing lateral X-ray at 1 month shows anterior shifting of loading axis of the head and deterioration of dropped head. (C) X-ray at 2 months shows multiple reconstruction failure (anterior cervical plate was dislodged, C2 pedicle screws were pulled out, and Th5 vertebra developed compression fracture). (D) Images after fourth operation (extension of posterior fusion with C0 to Th8). Standing lateral X-ray shows that the loading axis of the head still exists far anterior of the sternum (CGH-C7 SVA, 101 mm).
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Fifteen months after anterior fusion, she underwent a third operation, posterior fusion from C2 to Th5 (Fig. 4A). But the loading axis of the head still remained anterior to the sternum (Fig. 4B). Two months after the posterior fusion, reconstruction failure developed (Fig. 4C). In July 2016, she underwent a fourth operation, occipital-cervical-thoracic fusion (Fig. 4D), but this did not produce recovery of sagittal spinal balance to the normal range (center of gravity line from the head-C7 sagittal vertical axis (CGH-C7 SVA), 101 mm; C2-S1 SVA, 98 mm).