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Renaud Lafage, Justin S. Smith, Alex Moy Fong, Basel Sheikh Alshabab, Themistocles Protopsaltis, Eric O. Klineberg, Gregory Mundis Jr., Peter G. Passias, Munish Gupta, Christopher I. Shaffrey, Han Jo Kim, Shay Bess, Frank Schwab, Christopher P. Ames, Virginie Lafage, and


Hyperextension of C0–2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0–2 hyperextension and improved clinical outcomes.


A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2–7 and C0–2. The association between C2–7 correction and change in C0–2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2–7 percentiles.


Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2–7, −11.7° ± 18.2°; T1 slope–cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] −12.8 ± 71.2 mm), and hyperlordosis at C0–2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2–7 and C0–2, respectively, with an ROE of approximately 9° for each segment. Limited C0–2 ROM and ROE correlated with the Neck Disability Index (r = −0.371 and −0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2–7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0–2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to −49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0–2 ROM increased to 27.6° ± 8.1° and C2–7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2–7 lordosis significantly correlated with increased TK (r = −0.617, p < 0.001), decreased C0–2 (r = −0.747, p < 0.001), and increased C0–2 ROE (r = 0.550, p = 0.002).


CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0–2 ROE and TK and was also associated with improved clinical outcome.