A 7 year-old girl presented with a chief complaint of gradual restriction of cervical range of motion. Four years ago, her parents discovered the initial limited rotation of neck with subsequent limited flexion and eventual cervical hyperlordosis deformity. As she started school homework, the downward gaze difficulties became more prominent. The family asked for a major medical intervention when they found that she could not perform her school assignments. She had undergone 30 sessions of stretching exercise and positional traction, without satisfactory results.
The preliminary physical exams revealed thoracic hump, elevated right shoulder, extremely limited cervical flexion (active and passive); lateral cervical bending less than 10˚ and mild back pain due to awkward positions. The only finding in the physical exam of extremities was limited external bilateral hip rotation at less than 20˚. Absence of knee or hip flexion contracture, “W” sitting position, normal neurologic exam and lack of limping were other findings. A palpatory examination revealed a significant amount of bilateral muscle thickness and hardness in the paraspinal musculature about the C1 - C7 levels. Physical examination revealed no abnormal sensory, motor, or reflex findings. Bilaterally apparent lack of cervical rotation was recognized. The radiological examination revealed a 95˚ cervical hyperlordosis, significantly higher than the normal range of 34 - 42˚ (
2, 5). The cervical vertebrae bony architecture was normal. We found thoracic scoliosis of about 20 degrees at T4-T10 level, which required no surgical interventions.
The forward head posture (FHP), when measured from the sella turcica down to the anterior portion of the C4 disc, as outlined by Kapandji (
6), measured -60 mm. This value should be zero, according to Kapandji. Due to the cervical hyperlordosis, measurements of the FHP were also performed, using a vertical line from the posterior-superior corner of the C2 vertebral body down to the posterior inferior corner of the vertebral body of C7. This method is outlined by Harrison et al. ( 3, 5). The initial measurement, using this method, was 10 mm, which was in the normal range. In addition, we also measured the C7 sagittal tilt by drawing a line parallel to the inferior end plate of C7, and measuring that line against a line constructed horizontally. Initially, this angle measured 40˚ ( 2). The magnetic resonance imaging (MRI) study was not conclusive. Investigation by CT scan did not reveal any congenital vertebral abnormalities. Electromyography (EMG) and nerve conduction studies did not help to differentiate any spastic or neuromuscular underlying disease. There was no considerable response to conservative treatment including 30 sessions of SMT combined with positional traction. Botulinum injection was not recommended due to the lack of any spastic disorders. Therefore, she underwent surgical radical resection of cervical paraspinal muscles, followed by halo-traction. She was discharged with a halo-vest. The purpose of halo application was to prevent the recurrence of deformity. Specific instructions for home exercises were provided to the patient. Apparently, halo devices can be used safely in children as young as 1 year old. The advantages of halo-vest in comparison with other cervical orthosis are: 1. properly applied custom halo-vest avoids the skin breakdown complications; 2. the potential noncompliance of children with removable collars and orthosis favors the use of halo devices.
Post-trial radiographs showed a reduction of the cervical lordosis down to 51˚ and a reduction in FHP to 73 mm. Patient symptoms were significantly alleviated by the end of the aforementioned treatment.
General anesthesia was administrated in supine position. After administration of muscle relaxants, we did not achieve any evidence of cervical flexion. Then, we positioned the patient prone on a three-point head rest and avoid any excessive pressure on the eyes. After routine skin preparation, we attached the drapes to the neck with stay sutures. By a midline, longitudinal skin incision from the occiput to C7, the skin and subcutaneous tissues were undermined and paraspinal muscles were exposed. The trapezius was separated from underlying muscles by blunt dissection. The fascial sheath on the origins of the trapezius and rhomboid muscles was freed from the spinous processes by a sharp dissection. Afterwards, the origins of the splenius and semispinalis muscles were stripped from the occiput. About 3 cm of the proximal parts of the last muscles were excised for pathologic study. By gentle flexion of neck intraoperatively, we were able to evaluate the adequacy of the contracture release. The optimal release was revealed intraoperatively by chin-to-manubrium contact. Then, the midline fascia and nuchal raphe were repaired, while a drain was placed along the posterior aspect of the spine to prevent the formation of hematoma. The skin was closed in multiple layers. After dressing, the patient was placed in supine position and a halo ring was applied by introducing the pins in the appropriate locations. The initial traction was started by 2 lbs. and gradually increased to 6 lbs. over 2 weeks. The pathology report of the muscle specimen was normal. She was discharged from the hospital with a halo cast for 6 weeks. After halo ring removal, instructions for stretching exercises were provided.
The postoperative X-ray study showed that cervical lordosis had been reduced from 95˚ to 51˚, which falls closer to the normal range. In addition, the C7 sagittal tilt was also reduced from 40˚ to 28˚. The FHP, when measured from the sella turcica, changed from -60 mm to 13 mm. However, when it was measured from the posterior superior C2 body corner, the FHP was reduced from 10 mm to 6 mm. All changes are illustrated in
Figures 1 and 2.
Figure 1. C7 Sagittal Tilt
Figure 2. Forward Head Posture, When Measured From the Sella Turcica Down to the Anterior Portion of the C4 Disc. Preoperative and postoperative X-ray.