CHAPTER
125
Cervicothoracic Extension Osteotomy
for Chin-On-Chest Deformity
The author would like to acknowledge the assistance and guid-
ance of Dr. Henry Bohlman who pioneered the use of cervico-
thoracic osteotomy in the treatment of fixed kyphotic
deformities. Dr. Bohlmans foresight and skill, as well as his
commitment to education, have had untold influence on the
care of patients with spinal disorders.
INTRODUCTION
A fixed kyphotic deformity of the cervicothoracic spine result-
ing in chin-on-chest deformity is an uncommon although
severely disabling condition. Surgical correction with a poste-
rior cervicothoracic extension osteotomy can provide dramatic
restoration of head and neck posture and marked relief of pain
and improvement in function (Tables 125.1 and 125.2). The
goals of an extension osteotomy are to improve sagittal align-
ment and to restore the head to a more normal position in
relation to the thoracic spine.
The successful cervicothoracic extension osteotomy allows
for improved forward gaze resulting in more functional ambu-
lation, relief of spinal cord compression and nerve root trac-
tion, relief of dysphagia and dyspnea from kinking of the
esophagus and trachea, respectively, and prevention of atlanto-
axial subluxation by eliminating the biomechanical stress from
the head being carried in a forward position.
ETIOLOGY
Fixed chin-on-chest deformities are most commonly seen in
patients with ankylosing spondylitis. The primary flexion defor-
mity (fixed hyperkyphosis) in patients with ankylosing spon-
dylitis occurs most commonly in the thoracic and lumbar spine
but occasionally will primarily involve the cervicothoracic spine.
The chin-on-chest deformity results in problems with horizon-
tal gaze, gait, swallowing, personal hygiene, and neck pain and
may be accompanied by varying degrees of myelopathy due to
draping of the spinal cord over the kyphotic spinal column.
The deformity in ankylosing spondylitis may occur at any age
and may be associated with deformities in the thoracic and
lumbar spine. As the deformity reaches approximately 45, the
mere weight of the head will pull the cervical spine into increas-
LWBK836_Ch125_p1345-1354.indd 1345
Christopher G. Furey
ing kyphosis. The bone of the ankylosed spine is a living struc-
ture and will progressively remodel into the kyphotic position
until, in the most extreme case, the chin comes to rest upon the
sternum. Alternatively, the deformity may occur after a fracture
of the ankylosed cervical spine, with subsequent development
of a severe fixed kyphosis.
Other conditions such as postlaminectomy or posttraumatic
cervical kyphosis are less likely to result in a chin-on-chest
deformity. In these conditions, the deformities are generally
not as large or as rigid as those seen with ankylosing spondylitis
and less often require osteotomies for correction. In patients
with advanced spondylotic changes and longstanding muscle
contractions, however, a fixed deformity may arise similar to
those in patients with ankylosing spondylitis.
SURGICAL INDICATIONS
Patients with a chin-on-chest deformity typically have experi-
enced longstanding pain and disability. Indications for surgery
include severe neck pain, altered function, limited lifestyle, and
progressive deformity. As deformities approach 45, activities of
daily living and personal hygiene become increasingly difficult.
The ability to safely ambulate is limited as patients have diffi-
culty looking forward, even with compensation through pelvic
retroversion and knee flexion. In extreme cases, patients may
have difficulty feeding themselves.
While there is not a specific numeric threshold for the
degree of sagittal deformity at which surgery becomes abso-
lutely indicated, once a deformity is greater than 45, surgical
intervention should be considered, as it is at this point a patient
is likely to experience significant symptoms and functional lim-
itations. Progressive kyphosis on serial radiographic examina-
tions is also an indication for surgery and is commonly seen in
the patient with ankylosing spondylitis, as the bone of the spi-
nal column continues to remodel under the weight of the head.
It is desirable to correct a deformity before it has progressed to
the point where the chin is directly resting on the chest. Sagittal
alignment is a regional measurement made between lines per-
pendicular to an upper cervical vertebral end plate (C2 or 3)
and a midthoracic vertebral end plate. Successive measure-
ments should be made at identical levels to correctly assess
deformity progression.
1345
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 1346 Section XI Kyphosis and Postlaminectomy Deformities
Algorithm of Preparation
TABLE 125.1
for Corrective c.
1. Fixed kyphotic deformity identified
2. Full-length spine radiographs
a. identify all deformities
b. establish planned correction (Goal: 15 of residual
cervicothoracic kyphosis)
3. MRI scan
a. identify degree of spinal cord compression
b. identify intraspinal pathology (rare)
4. Thorough preoperative medical management
a. cardiac ultrasound (detect aortic stenosis)
b. nutritional assessment (identify and correct deficiencies)
c. bone density scan (identify and treat osteoporosis)
d. serum cotinine levels (confirm smoking cessation)
5. Anesthesia consultation
a. selection of experienced anesthesia colleague
b. patient education of planned anesthesia protocol
6. Halo ring application
7. Custom Risser cast application
MRI, magnetic resonance imaging.
Posterior cervical corrective osteotomy is contraindicated
when a patient has a thoracolumbar kyphosis that is of greater
magnitude than that of the cervical spine. If deformities in the
cervical and thoracolumbar spine are similar, it is suggested
that the cervical spine be corrected first, so that subsequent sur-
gery and the necessary general anesthetic may be more safely
obtained. General contraindications include prohibitive car-
diac or pulmonary conditions and impaired mental health or
psychiatric conditions that would affect the ability to cooperate
with postoperative recovery and rehabilitation. Smoking should
be considered an absolute contraindication, as most patients
with ankylosing spondylitis have some degree of restrictive lung
disease, so that optimizing preoperative pulmonary function is
essential. In addition, the adverse effect of nicotine on bone
and soft tissue healing must be eliminated by absolute smoking
cessation.
OPERATIVE TECHNIQUE
PREOPERATIVE PLANNING
All patients must be thoroughly evaluated from a medical
standpoint with an emphasis on cardiac and pulmonary status.
Aortic stenosis is prevalent in patients with ankylosing spondyli-
tis, thus a cardiac ultrasound should be part of the preoperative
evaluation. Any patient with a history of smoking must be eval-
uated for the presence of nicotine metabolites in the serum or
urine to ensure compliance with smoking cessation. The
patients nutritional status should be evaluated; advanced
deformities may affect the ability to swallow solids and lead to
malnutrition. Patients with spondyloarthropathies may also
experience ileitis or colitis, further affecting their nutritional
status. Bone density may be poor in these patients so there
exists the potential for problems with fixation and bone heal-
ing. When the potential of nutritional deficiency exists, a bone
density scan is obtained to identify osteoporosis, which, if pres-
ent, should be treated. A preoperative consultation with expe-
rienced anesthesia personnel is essential, because of the critical
LWBK836_Ch125_p1345-1354.indd 1346
Algorithm of Surgical
TABLE 125.2 Technique Corrective
Cervicothoracic Osteotomy
1. Positioning
a. patient awake and sitting upright
b. halo ring support via rope to overhead pulley
c. custom-fit Risser cast in place
d. arms and legs well padded
2. Surgical exposure
a. infiltration with local anesthetic
b. midline exposure (C5-T2)
c. subperiosteal dissection to tips of lateral masses
d. deep fascial sutures placed initially (prior to osteotomy)
e. spinous process wires placed prior to osteotomy (alternatively:
lateral mass and pedicle screws placed)
3. C7-T1 osteotomy
a. laminectomies of C6, C7, T1
b. complete C7-T1 foraminotomies (C8 root entirely exposed)
c. C7 pedicle and superior aspect of T1 pedicle removed
d. brief general anesthetic during manual correction
e. correction via slow, manual traction on halo ring
f. visual inspection of corrected position
g. application of Luque ring to previously placed wires
(alternatively: rods to previously placed screws)
h. general anesthetic reversed and neurologic assessment
performed
i. morcelized local bone graft placed
4. Closure
a. via previously placed deep fascial sutures
b. subcutaneous and skin closure
c. halo ring secured to Risser cast
supportive role played by the anesthesiologist during the pro-
cedure, much of which is performed with the patient awake.
Full-length radiographs of the entire spinal column are
obtained to assess the magnitude of the cervicothoracic defor-
mity and to determine the presence and magnitude of deformi-
ties within the thoracolumbar spine. Magnetic resonance imag-
ing (MRI) scans should be routinely obtained to evaluate the
degree of spinal cord compression and to detect the unlikely
possibility of intraspinal pathology.
The chin--brow to vertical angle measures the degree of flex-
ion deformity in patients with ankylosing spondylitis and is use-
ful to predict the anticipated degree of postoperative correc-
tion. The chin--brow to vertical angle is the angle between a
line connecting the chin and brow and a vertical line with the
patient standing with the hips and knees extended and the
neck in the neutral position (Fig. 125.1). In general, the amount
of planned correction should leave the patient with 10 to 15
of residual kyphosis. Overcorrection of the kyphosis can leave
the patient without the ability for downward gaze. In patients
who have severe fixed deformities of both the cervical and tho-
racolumbar spines, it is suggested to address the cervical spine
first, so that subsequent surgical procedures are not compli-
cated by the difficulty of obtaining successful intubation that
would occur with a fixed chin-on-chest deformity.
Each patient should be fit preoperatively with a halo ring
and custom-made Risser cast. A standard halo vest will not ade-
quately fit the kyphotic dimensions of a patients thoracolum-
bar kyphosis, nor will it provide adequate fixation of the torso
and pelvis. In addition, it is necessary to conform the posterior
aspect of the thoracic cast vest to allow sufficient room for the
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 Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity
Figure 125.1. The chin--brow to vertical angle is the angle
between a line connecting the chin and brow and a vertical line with
the patient standing with the hips and knees extended and the neck
in the neutral position.
sterile operative field and to provide an adequate abdominal
hole to allow for abdominal breathing, as most patients have
limited chest expansion and depend greatly on abdominal
mechanisms for breathing.
ANESTHESIA
The majority of the procedure is performed with the patient
sedated but awake. The patient is lightly premedicated with an
infusion of midazolam. Monitoring equipment includes an
arterial line, an electrocardiogram (EKG), a noninvasive blood
pressure cuff, a pulse oximeter, and a precordial Doppler
probe. A nasal airway is placed after a topical anesthetic has
been applied to the nares. A clear, light face mask is place to
deliver continuous oxygen flow. Short-acting agents such as ket-
amine or propofol are administered continuously to allow the
patient to remain sedated but conscious and able to follow ver-
bal commands. A brief anesthetic is performed at the time of
the corrective osteotomy.
POSITIONING
The patient is placed in the sitting position with the head and
neck in the upright fashion (Fig. 125.2). The halo ring is
secured to an overhead pulley (suspended from the ceiling)
with 10 lb. The patient is strapped into the seated position so
that there is no sliding forward at the time of the osteotomy. A
pillow is placed under the flexed knees and pillows placed
under the elbows to allow the arms to rest freely.
SURGICAL TECHNIQUE
A midline approach is made to expose the posterior aspect of
the lower cervical and upper thoracic spines. Prior to the skin
LWBK836_Ch125_p1345-1354.indd 1347
1347
Figure 125.2. Lateral view of the patient from Illustrative Case
125.1 in the sitting position in the operating room. The arms are
comfortably propped on pillows, and the patient is strapped onto the
table. The halo ring is suspended directly overhead to a pulley in the
ceiling. The operating surgeon stands behind the patient to perform
the surgery.
incision, local anesthetic (0.75% bupivacaine [Marcaine] with
epinephrine diluted in saline in a 1:2 ratio) is infiltrated in the
subcutaneous and paraspinal musculature and down to and
including the periosteum of the spinous processes and laminae
of C5-T2. A standard subperiosteal dissection is performed to
expose from C5-T2, to include the complete lateral extent of
the posterior aspect of the spine. A radiograph is obtained to
confirm exposure of the appropriate levels. It is helpful to place
the deep fascial sutures immediately after the initial surgical
exposure has been performed, as the wound becomes mark-
edly deformed following the corrective osteotomy and ana-
tomic closure of the deep layers is difficult unless those sutures
have been placed beforehand.
The instrumentation employed for internal fixation should
be applied prior to the decompression and corrective osteot-
omy. This allows a safer scenario in which the handling and
insertion of fixation devices is not performed over the exposed
spinal cord. With instrumentation already in place, internal sta-
bility can also be expeditiously obtained once the osteotomy
has been performed. Spinous process wiring and a Luque rect-
angle can be safely and easily employed as instrumentation
devices. Sixteen-gauge wires with Drummond buttons are
placed through holes drilled in the spinous processes of C6 and
T1 or T2. The wires are then tucked under the retractors to
allow an open field to perform the subsequent decompression.
A Luque rectangle is selected and prebent to accommodate the
dimensions of the corrected spine following the osteotomy.
Alternatively, lateral mass screw fixation in the cervical spine
and pedicle screw fixation in the thoracic spine may be used,
although it may not be performed with same the ease an speed
as wiring.
C7-T1 is selected as the leel to perform the osteotomy to
afford maximal correction through the cervicothoracic junc-
tion. The spinal canal is sufficiently wide at this level, and there
is adequate mobility of the C8 roots to reduce the likelihood of
iatrogenic spinal cord or nerve root injury. Equally important,
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 1348 Section XI Kyphosis and Postlaminectomy Deformities
C6
Removal of spinous
processes and
lamina C6-T1
T1
Figure 125.3. Illustration of wide surgical exposure and removal
of spinous processes at the beginning of the decompression.
the vertebral artery enters the transverse foramina at C6;
performing the osteotomy caudal to this level decreases the
chance of injury to it during the exposure and correction. A
laminectomy is performed at C6, C7, and T1 (Fig. 125.3). A
3-mm high-speed burr is used to create laminectomy troughs to
the ventral cortex of each lamina, and the laminectomy is com-
pleted with fine, angled microscopic-type Kerrison rongeurs. In
this fashion, no excessive pressure is exerted on the contents of
the spinal canal. The laminae are then lifted as a unit, taking
care to identify any dural adhesions. Bipolar cautery is used
to control the epidural venous bleeding that is frequently
encountered.
Once the laminectomies have been performed, the exiting
C8 nerve roots should be completely unroofed so that they can
be traced from their origins laterally into the soft tissue. The
high-speed burr is used to decorticate the C7-T1 facet joints
down to the ventral cortical bone and once again the fine-
angled Kerrison rongeur is used to complete the foramino-
tomy and expose the exiting C8 roots bilaterally (Figs. 125.4A
and B). The foraminotomy must be extended all the way later-
ally into the soft tissue so that there is no bone bridge that
would limit the completion of the osteotomy or lead to C8
nerve root compression as the osteotomy is closed. The C7
pedicle and the superior aspect of the T1 pedicle are burred
away ventrally to the posterior cortex of the vertebral body, to
further provide adequate room for the C8 root at the time of
the osteotomy and correction. During the nerve root decom-
pression, the patient may experience paresthesias in the C8
distribution. This can be remedied by application of cottonoid
patties soaked in local anesthetic, although care should be
taken to avoid placement of the patties centrally over the the-
cal sac, as the anesthetic might directly anesthetize the spinal
cord.
LWBK836_Ch125_p1345-1354.indd 1348
With an adequate central and foraminal decompression
performed (and with the instrumentation in place) the osteot-
omy is performed (Figs. 125.5 and 125.6). The surgical and
anesthesia teams prepare themselves to carry out the osteotomy
in a coordinated fashion. The assistant surgeon moves to the
front of the patient and grasps the halo ring. A brief general
anesthetic is started when the osteotomy is to be performed.
The operative surgeon begins slow posterior traction on the
halo ring until sufficient correction is obtained. The osteotomy
(a closed anterior osteoclasis) occurs at the level of the C7-T1
disc space. As the corrected position is obtained, there is wrin-
kling of the dura (Fig. 125.7). As the assistant surgeon holds
the head in the corrected position, the primary surgeon walks
to the front of the patient to evaluate the corrected position, by
assessing the alignment of the chin and brow in relation to the
patients chest. If a preoperative rotary deformity exists in addi-
tion to the fixed kyphosis, additional bone may be removed on
one side to correct the rotational component. If the position is
acceptable, the morcelized local bone graft can be placed in
the lateral gutters after the lateral masses and facet joints have
been decorticated (Fig. 125.8). The prebent Luque rectangle is
then slid down on either side of the spinous process wires,
which are then tightened and trimmed (Fig. 125.9). Alternatively,
prebent rods can be secured to the previously placed screws. At
the completion of the fixation, the patient is awakened and
asked to move all extremities to document that no neurological
deficit has occurred.
The wound is then closed in layers. A suction drained is
placed deep to the fascia. The assistant surgeon has continued
to hold the head in the corrected position until the wound is
completely closed and a soft dressing placed at which point the
halo ring is attached to the custom-molded plaster cast. The
patient is monitored in the postanesthesia care unit until fully
awake.
POSTOPERATIVE CARE
Patients are mobilized rapidly on the first postoperative day.
Drains are generally removed on the second postoperative day.
A liquid diet is begun, as tolerated, on the first or second post-
operative day. Dysphagia may be a problem for some patients,
as the esophagus is tented about the osteotomy site and as the
patient learns to accommodate for the new head position and
the restraints of the halo vest. Most patients are able to tolerate
at least a modified solid diet by the time of discharge. Require-
ments for discharge include independent ambulation, ade-
quate nutritional status, and use of oral analgesics.
The halo vest is employed for 3-months postoperatively. At
this point, plain radiographs and a fine-cut computed tomogra-
phy (CT) scan with coronal and sagittal reconstructions are
obtained to confirm healing of the fusion and osteotomy. If
healing is adequate, a hard collar is placed for additional
3 months and if at that time radiographs continue to confirm
solid fusion, all immobilization is discontinued.
COMPLICATIONS
The most serious complications are death and paralysis, but
these events are fortunately quite rare in most published
series. With the exception of a brief period of general anes-
thetic during the corrective osteotomy, the patient is sedated,
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 Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1349

Laminectomy C6
Decompressed
Bone removed
c8 n.

Laminectomy T1 Removal of
C7 pedicle
(diamond burr)

Figure 125.4. (A) Illustration of the completed decompression, with exposure from C6 through T1. The
burr is removing the inferior portion of the C7 pedicle. (B) Photograph of the completed decompression;
cottonoid patties cover the thoroughly unroofed C8 nerve roots.

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 1350 Section XI Kyphosis and Postlaminectomy Deformities

Head extended
manually

Bone chips

Decompressed
C8 n.

Gelfoam

Figure 125.5. Illustration of the head position during the osteot-

omy; this is controlled by the operative surgeon from posterior and
the assistant from anterior.

Figure 125.8. Illustration of the previously placed spinous process

wires in position and bone graft being placed laterally. Gelfoam
covers the dura.

Laminectomy
C7 C6, C7, T1
C7
T1 Avulsion
fracture

PREOP POSTOP

Figure 125.6. Illustrations of the level of the osteotomy and the

pre- and postoperative alignment.

Luque
rectangle

Dura
buckles

Figure 125.9. The Luque rectangle has been placed and the wires
T2 tightened.

Figure 125.7. Illustration of the dura buckling as the osteotomy

has been completed.

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 Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity
but awake and able to respond to verbal stimulation from the
anesthesiologist. In the event of cardiac or respiratory deterio-
ration, intervention can be immediate. Spinal cord monitor-
ing is generally not performed as a patients direct response is
obtained by verbal questioning from the anesthesiologist.
With the patient awake, adverse neurological events should be
immediately detected and surgical alterations can be made
promptly.
With dramatic correction in patients with longstanding
chin-on-chest deformity, the anterior cervical musculature
may become tight following correction. This causes stress
on the instrumentation and loss of correction may occur.
Instances of devastating neurological consequences from loss
of correction and ensuing spinal cord compression have been
described. However, with the use of both internal fixation and
halo vest immobilization typically the correction will not be
disrupted. In the event that tight anterior musculature threat-
ens to disrupt the osteotomy or is causing severe dysphagia,
surgical tenotomies of the sternocleidomastoid muscles may
be indicated.
Late loss of correction or pseudarthrosis at either the osteot-
omy site or posterolateral fusion is also uncommon if rigid
internal fixation and adequate post-operative immobilization
are employed. Careful radiographic surveillance is essential to
document maintenance of correction and appropriate boney
healing.
C8 nerve root palsy may occur if an adequate decompres-
sion is not performed, underscoring the importance of com-
plete C7-T1 foraminotomy and partial pedicle resection of each
level prior to the corrective osteotomy. The C8 roots must be
carefully inspected after closure of the osteotomy to ensure
that no nerve compression exists. A mild C8 palsy may nonethe-
LWBK836_Ch125_p1345-1354.indd 1351
1351
less occur in some cases. These generally resolve over time with
supportive treatment alone.
CONCLUSION
The profound disability that occurs with a fixed chin-on-chest
deformity can be addressed with a posterior cervicothoracic
extension osteotomy. Careful preoperative planning and atten-
tion to detail with surgical technique help to ensure a successful
outcome. Patients with equally severe cervicothoracic and thora-
columbar deformities should have the cervical osteotomy per-
formed first as this will allow for safe endotracheal intubation for
subsequent surgeries. An experienced anesthesiologist who is
actively involved prior to surgery and with whom open communi-
cation is maintained during surgery is of paramount importance.
A well-molded plaster vest should be fit individually for each
patient preoperatively, conforming to his or her unique spinal
dimensions and allowing for an adequate surgical field. The
C7-T1 level is the typical level for the osteotomy. A wide decom-
pression is essential, and special attention is paid to the C8 nerve
roots to avoid postoperative palsy. Internal fixation should be
placed prior to the decompression to allow for safe and expedient
internal stabilization once the osteotomy is performed. Choice of
fixation device is based on surgeon preference, although spinous
process wires with Drummond buttons secured to a Luque rect-
angle has a proven track record clinically and is safe and easily
placed. The osteotomy itself is directly performed and inspected
by the primary surgeon, with care to maintain 10 to 15 of resid-
ual kyphosis to avoid overcorrection. Careful clinical and radio-
graphic surveillance postoperatively is critical to confirm the
maintenance of correction and appropriate boney healing.
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 1352 Section XI Kyphosis and Postlaminectomy Deformities

ILLUSTRATIVE CASE 125.1

A 38-year-old man with ankylosing spondylitis presented kyphosis (Fig. 125.10C). He underwent a posterior correc-
with severe neck pain, inability to look forward, and great tive osteotomy with dramatic improvement clinically
difficulty with hygiene and swallowing (Figs. 125.10A and (Fig. 125.11A) and radiographically (Figs. 125.11B and C).
B). A lateral radiograph revealed fixed cervicothoracic

A B

C
Figure 125.10. (A to C) Preoperative photographs and lateral
radiograph of Case 125.1.

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 Chapter 125 Cervicothoracic Extension Osteotomy for Chin-On-Chest Deformity 1353

A B

Figure 125.11. (A to C) Postoperative lateral photograph and

C radiograph of Case 125.1 revealing excellent clinical correction of
alignment and radiographic healing of osteotomy.

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 1354 Section XI Kyphosis and Postlaminectomy Deformities

ILLUSTRATIVE CASE 125.2

A 47-year-old man with previously undiagnosed ankylosing extension osteotomy was performed with halo vest immobi-
spondylitis presented with a fixed chin-on-chest deformity, lization. At 10-year follow-up, his correction was maintained
severe neck pain, and both subjective and objective evidence clinically and he remained employed as a laborer
of myelopathy (Fig. 125.12). A posterior cervicothoracic (Fig. 125.13).

Figure 125.12. Preoperative photograph of Case 125.2 revealing

deformity and patient wearing custom-made plaster body cast. Figure 125.13. Postoperative photograph of Case 125.2 revealing
maintenance of corrected alignment at 10-year follow-up.

10. Mason C, Cozen L, Adelstein L. Surgical correction of flexion deformity of the cervical
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