Correction strategy for osteomyelitis-associated cervical deformity with illustrative 2D operative video: illustrative case.

backgroundThe authors present the case of a 44-year-old female with a history of intravenous drug use who previously underwent C2-4 anterior cervical discectomy and fusion for a retropharyngeal and ventral epidural abscess. Following a 1-year hiatus in clinical follow-up, she presented with progressive cervical myelopathy, intractable neck pain, and profound postural decompensation. Imaging confirmed severe mid-cervical kyphosis, coronal malalignment secondary to chronic osteomyelitis, and significant hardware subsidence, resulting in severe stretch myelopathy. OBSERVATIONS: A two-stage reconstructive approach was utilized to achieve spinal cord decompression, restoration of the anterior column, and correction of complex plane deformities. Stage 1 involved intraoperative traction, explantation of failed hardware, C3-6 corpectomies, and reconstruction with an expandable cage with screw fixation. Stage 2 involved C6-7 laminectomies and posterior instrumentation from C2 to T2. At the 18-month follow-up, she maintained her radiographic correction with significant neurological recovery. LESSONS: This case underscores the necessity of rigorous postoperative surveillance in patients with spinal infections, particularly those with existing instrumentation, as follow-up gaps can mask insidious deformity progression. Furthermore, chronic osteomyelitis often obscures surgical landmarks through soft tissue hypertrophy and scarring. Achieving wide exposure to define reliable anatomical landmarks is paramount to safely navigating the operative field and protecting the vertebral arteries. https://thejns.org/doi/10.3171/CASE26453.