Cervical Kyphotic Deformity

What is cervical kyphotic deformity?

“Cervical deformity” refers to a pathologic change in cervical alignment—most commonly loss of lordosis with development of kyphosis—often accompanied by pain and, in many cases, neurologic symptoms.

Normally, the neck has a gentle lordotic curve that allows the head to balance comfortably above the torso. In cervical kyphosis, the curve “reverses,” which can lead to:

• forward translation of the head (forward-head posture),
• increased load on posterior muscles and ligaments,
• an altered relationship between the spinal cord and the spinal canal, with possible stenosis and compression.

Deformity may begin in childhood (congenital or neuromuscular) or develop in adulthood (degenerative, iatrogenic, post-traumatic). Severity ranges from mild postural change to rigid “chin-on-chest” deformity with inability to maintain a horizontal gaze.

How does the cervical spine work biomechanically?

Cervical balance is maintained by the interplay of the anterior column (vertebral bodies, discs) and the posterior complex (laminae, facet joints, ligaments, muscles).

Unlike the lumbar spine—where the anterior column bears most axial load—in the cervical spine a substantial portion of load is carried by posterior elements (facets and the muscle–ligament “tension band”). The anterior structures (bodies/discs) primarily resist compressive forces, while the posterior complex functions as a “tension band” resisting tensile forces.

When posterior structures are weakened, disrupted, or removed (for example after extensive laminectomy), the head’s load axis shifts forward, overloading the anterior column and discs. This can trigger a vicious cycle of progressive kyphosis, pain, and accelerated degeneration.

What are the most common causes?

Causes are often multifactorial. Certain patient groups, however, carry a distinctly higher risk.

Main etiologic categories include:

1) Degenerative (age-related) disease

• Chronic cervical spondylosis with disc height loss and facet arthropathy.
• Progressive collapse into flexion with muscular fatigue and postural decompensation.

2) Iatrogenic (post-surgical)

• Extensive posterior laminectomy without stabilization, leading to paraspinal muscle weakness and disruption of the posterior “tension band.”
• Over-resection of facets or their capsules, resulting in instability and kyphotic collapse.
• In pediatric populations, combined suboccipital decompression and posterior element resection can be associated with particularly high kyphosis rates.

3) Congenital & neuromuscular conditions

• Congenital syndromes (e.g., Larsen syndrome; other skeletal dysplasias).
• Neurofibromatosis type 1 with structural instability.
• Neuromuscular disorders and cervical dystonia with chronic spasm.

4) Trauma, tumors, infections

• Fractures or ligament disruptions with loss of support.
• Tumors that compromise bone and stabilizing structures.
• Infections (e.g., spondylodiscitis) causing disc and vertebral body destruction.

How does it present clinically—what symptoms occur?

Each patient may experience a different combination of symptoms—from primarily mechanical pain to advanced myelopathy.

Common symptoms and signs include:

• Neck pain (often deep/mechanical, worse with fatigue or prolonged posture).
• Inter-scapular pain due to paraspinal muscle overuse.
• Loss of horizontal gaze—difficulty looking straight ahead; the head tends to remain flexed (“chin-on-chest deformity”).
• Reduced neck mobility, stiffness, a sense of “tightness.”
• Tension-type headaches from muscular load.
• In advanced cases: dysphagia and/or voice changes.

Many patients report that the key burden is not pain alone, but the functional inability to stand, walk, read, or work while keeping the head upright and the eyes level.

What are the neurologic risks (myelopathy, radiculopathy)?

Cervical deformity is not “just posture.” It can result in chronic spinal cord compression and progressive cervical myelopathy.

Potential neurologic consequences include:

• Cervical myelopathy — numbness, loss of fine motor control in the hands, clumsiness, weakness, lower-extremity spasticity, gait imbalance, hyperreflexia, and pathologic signs (Hoffmann/Babinski).
• Radiculopathy — pain, numbness, or weakness in a specific dermatomal/myotomal pattern, typically due to foraminal stenosis and root compression.
• In severe cases — bladder dysfunction, frequent falls, and major functional decline.

Kyphosis can worsen stenosis: in flexion the spinal cord is forced to “drape” over the kyphotic segment and becomes tethered by denticulate ligaments and exiting roots, increasing vulnerability. The combination of mechanical compression and microvascular compromise can drive progressive myelopathy.

Which imaging is needed (MRI, CT, dynamic/full-length X-rays)?

Evaluation is multi-dimensional—a single test is rarely enough. We assess both regional alignment and overall sagittal balance.

Typical studies include:

• Cervical MRI — evaluates the spinal cord, roots, discs, ligaments, posterior elements, and identifies cord signal change (e.g., T2 hyperintensity) when present.
• Plain X-rays (AP & lateral), including flexion–extension (dynamic) views to assess instability and flexibility.
• Cervical CT — detailed osseous anatomy for planning osteotomies and complex reconstruction.
• Full-length spine radiographs (36-inch long cassette) — assessment of global sagittal alignment (head–thorax–lumbar spine–pelvis).
• Vascular imaging (MRA/CTA, and DSA in selected cases) — when major osteotomies are planned near critical vascular structures (e.g., vertebral arteries).

When is non-surgical treatment enough—and what does it include?

Not every cervical kyphotic deformity requires surgery. In mild or minimally symptomatic cases, non-surgical treatment is usually the first-line approach.

Conservative management may include:

• Physical therapy — posture training, targeted strengthening of cervical extensor/paraspinal muscles, stretching.
• Medication — analgesics, muscle relaxants; in selected cases neuropathic agents.
• Epidural steroid injections for significant radicular pain when appropriate.
• Cervical collar — short-term use as a temporary unloading strategy, not as a long-term solution.

Conservative care does not reverse kyphosis, but it can reduce symptoms and slow progression. Close follow-up is essential: worsening pain, new neurologic signs, or progressive postural decline may shift the strategy toward surgery.

When is surgery needed and what are the goals?

Corrective surgery for cervical deformity is highly specialized and technically demanding. It is not performed for cosmetic reasons alone, but primarily to restore function and protect the spinal cord.

Common indications include:

• Symptomatic myelopathy (clinical signs and/or MRI evidence such as cord signal change).
• Inability to maintain horizontal gaze (“chin-on-chest” with major functional disability).
• Severe, persistent pain refractory to appropriate conservative measures.
• Progressive deformity or documented instability on dynamic radiographs.
• Dysarthria, dysphagia, or respiratory compromise related to head/neck position.

Core goals of surgery:

• Decompression of the spinal cord and nerve roots.
• Correction of alignment with restoration of physiologic or functionally acceptable lordosis.
• Stabilization (fusion) to maintain correction over time.
• Improved horizontal gaze, posture, and capacity for daily activities.

Which surgical strategies are used (anterior/posterior/circumferential)?

Surgical planning is individualized and depends on etiology, location, severity, and flexibility of the deformity.

Assessing curve flexibility

Using CT, dynamic X-rays, and—in selected cases—preoperative traction (Gardner–Wells tongs or halo traction), we determine whether the deformity is:

• Flexible — corrects with traction/motion, often treated with stabilization and fusion.
• Rigid — requires osteotomies (e.g., corpectomy-based correction, pedicle subtraction osteotomy).

Approach options

• Anterior approach: discectomy/corpectomy, cages/grafts, and plates/screws. Offers lordosis restoration, but correction can be limited in severe, rigid kyphosis.
• Posterior approach: decompression, osteotomies (e.g., facetectomies; selected high-impact osteotomies at the cervicothoracic junction), and screw–rod fixation. Provides powerful posterior support and can achieve substantial correction.
• Circumferential (360°) strategy: combined anterior and posterior reconstruction for maximal correction and durability, especially in rigid, high-grade deformities.

Fusion typically spans the full deformity and often extends into the upper thoracic spine (e.g., to T2–T3) to reduce failure risk at the cervicothoracic junction.

What are the risks & complications of corrective surgery?

Corrective cervical deformity surgery is a major operation with meaningful complication risk, which is why careful patient selection and an experienced deformity team are essential.

Potential complications include (non-exhaustive):

• Neurologic — transient or permanent radiculopathy; worsening myelopathy.
• Iatrogenic injury to the spinal cord or nerve roots during correction/osteotomies.
• Dural tear with CSF leak.
• Infection or postoperative hematoma.
• Dysphagia, hoarseness, recurrent laryngeal nerve palsy with anterior surgery.
• Instrumentation failure or pseudarthrosis requiring revision.
• General risks — thromboembolism, pulmonary complications, cardiovascular events.

Risk mitigation may include intraoperative neuromonitoring (SSEPs, TcMEPs), strict hemodynamic control, navigation/fluoroscopy for safe instrumentation, and—when indicated—intraoperative traction (e.g., Gardner–Wells tongs).

What is recovery and rehabilitation like?

Recovery is gradual and requires coordinated work between patient, family, and the rehabilitation team.

Typical elements include:

• Hospital stay of several days (ward vs ICU depending on complexity).
• Cervical collar for a period determined by the surgical team.
• Progressive mobilization with physiotherapy, training in safe movement patterns, posture, and gait.
• Scheduled imaging follow-up to confirm stability and progression toward solid fusion.
• Neurologic monitoring and tailored rehabilitation progression.

The goal is a stable, functional cervical posture, pain reduction, and improved independence in daily life (walking, self-care, reading, and—when permitted—driving).