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J. Patrick Johnson, Carl Lauryssen, Helen O. Cambron, Robert Pashman, John J. Regan, Neel Anand and Robert Bray


The authors evaluated cervical spine radiographs to determine sagittal alignment in patients who underwent one- or two-level arthroplasty with the Bryan cervical artificial disc prosthesis.


The curvature of the surgically treated spinal segments and the overall curvature of the cervical spine were evaluated in 13 patients who underwent 16 cervical arthroplasty device placements. Preoperative and postoperative lateral radiographs were reviewed and compared using standardized techniques for measuring spinal curvature. Patients who underwent a single-level cervical arthroplasty had a 4.7° mean reduction (p < 0.05) in lordosis after cervical artificial disc replacement. The three patients who underwent two-level cervical arthroplasty had no significant changes in the sagittal alignment.


Patients who underwent arthroplasty with a Bryan cervical artificial disc had a focal loss of lordosis (that is, kyphosis) at the treated levels after single-level procedures. Nevertheless, there was no significant change in the overall sagittal curvature of the cervical spine after single-level artificial disc replacements. The patients who underwent two-level artificial disc placement had no significant changes in lordosis at the treated levels or in the overall curvature. The likely source of this outcome appears to be the endplate milling procedures that reorient the vertebral endplates.

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Srinath Samudrala, Shoshanna Vaynman, Ty Thiayananthan, Samer Ghostine, Darren L. Bergey, Neel Anand, Robert S. Pashman and J. Patrick Johnson

mass. This method has its fulcrum through the anterior spinal column and ultimately “shortens” the spinal canal. It also results in bone-on-bone contact in all 3 columns to facilitate fusion. In this study, we characterize CTJ deformity and describe how PSO performed at the CTJ can be used to correct the regional sagittal alignment of the cervical spine and the location of the head in relation to the thoracic spine. We report the surgical technique and the postoperative results following osteotomy at the CTJ in 8 patients. Methods We identified and conducted a

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Neel Anand, Eli M. Baron and Babak Khandehroo

was less than 50 mm compared with postoperative SVA greater than 50 mm ( Table 3 ). The implication here is that other techniques may be necessary to achieve optimal sagittal alignment in cases of greater than 100 mm positive sagittal balance ( Fig. 5 ). Other techniques such as minimally invasive anterior longitudinal ligament release, 9 anterior lumbar interbody fusion (ALIF) at L5–S1, or posterior column osteotomies may afford increased lordosis, and thus, better result in correction of the SVA. In terms of achieving a postoperative pelvic incidence minus lumbar

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J. Patrick Johnson, Robert S. Pashman, Carl Lauryssen, Neel Anand, John J. Regan and Robert S. Bray

body habitus and spinal column alignment that may exhibit a characteristic asymmetrical hump in the presence of significant scoliotic deformity ( Fig. 6 ). Full-length (36 × 14—in) standing spinal radiography is performed to assess the overall spinal balance ( Fig. 2 ). Cobb angles are measured on these radiographs by using a goniometer in both AP and lateral orientations (briefly, a perpendicular line is drawn from the endplates of the most angulated vertebrae involved in the pathological curve [ Fig. 7 ]). Coronal and sagittal alignment is assessed using a plumb

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Paul Park, Michael Y. Wang, Virginie Lafage, Stacie Nguyen, John Ziewacz, David O. Okonkwo, Juan S. Uribe, Robert K. Eastlack, Neel Anand, Raqeeb Haque, Richard G. Fessler, Adam S. Kanter, Vedat Deviren, Frank La Marca, Justin S. Smith, Christopher I. Shaffrey, Gregory M. Mundis Jr. and Praveen V. Mummaneni

, including adult spinal deformity (ASD). Anand et al. 3 initially reported the feasibility of applying several different MIS techniques to treat symptomatic lumbar scoliosis. Subsequent reports have all confirmed successful MIS treatment of ASD. 5 , 17 , 21 , 24 These studies, however, have been limited by the relatively small numbers of patients evaluated, as well as the lack of focus on sagittal alignment and spinopelvic parameters, which are factors known to significantly impact long-term disability. 12 , 18 In addition, there has been no uniform MIS technique or

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Khoi D. Than, Paul Park, Kai-Ming Fu, Stacie Nguyen, Michael Y. Wang, Dean Chou, Pierce D. Nunley, Neel Anand, Richard G. Fessler, Christopher I. Shaffrey, Shay Bess, Behrooz A. Akbarnia, Vedat Deviren, Juan S. Uribe, Frank La Marca, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Praveen V. Mummaneni and the International Spine Study Group

that the spines of patients who do the worst are not appropriately corrected in the sagittal plane and are perhaps fused into a fixed sagittal plane deformity. The increased mean SVA in both groups probably represents the limited ability to improve sagittal alignment with early MIS techniques. Similarly, the unchanged PILL mismatch in the worst group reflects a lack of sagittal alignment improvement obtained by the early MIS approaches we used. These results highlight the basis of the MISDEF algorithm we created to guide MIS versus open treatment in patients with

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Praveen V. Mummaneni, Paul Park, Christopher I. Shaffrey, Michael Y. Wang, Juan S. Uribe, Richard G. Fessler, Dean Chou, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Robert K. Eastlack, Pierce D. Nunley, Neel Anand, Michael S. Virk, Lawrence G. Lenke, Khoi D. Than, Leslie C. Robinson, Kai-Ming Fu and the International Spine Study Group (ISSG)

close to or within normal thresholds. Although the degree of coronal curvature correction has been shown to be significant, the major concern with minimally invasive approaches has been its impact on sagittal alignment. Early minimally invasive approaches consisted mainly of multilevel LLIF or MIS transforaminal lumbar interbody fusion (TLIF) in conjunction with percutaneous fixation. 2 These interbody techniques, however, in many cases result in relatively small increases in segmental and regional lordosis. 11 Consequently, in cases in which there is significant

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Paul Park, Kai-Ming Fu, Praveen V. Mummaneni, Juan S. Uribe, Michael Y. Wang, Stacie Tran, Adam S. Kanter, Pierce D. Nunley, David O. Okonkwo, Christopher I. Shaffrey, Gregory M. Mundis Jr., Dean Chou, Robert Eastlack, Neel Anand, Khoi D. Than, Joseph M. Zavatsky, Richard G. Fessler and the International Spine Study Group

involved either a combination of approaches, such as multilevel lateral lumbar interbody fusion (LLIF), and/or MIS transforaminal lumbar interbody fusion (TLIF) followed by percutaneous fixation or hybrid surgeries typically involving LLIF combined with open posterior surgery. However, one of the potential disadvantages of MIS is that if more advanced techniques, such as anterior column realignment, are not performed, inadequate sagittal correction is a possibility. In the treatment of spinal deformity, there is substantial evidence that sagittal alignment is correlated

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Paul Park, Khoi D. Than, Praveen V. Mummaneni, Pierce D. Nunley, Robert K. Eastlack, Juan S. Uribe, Michael Y. Wang, Vivian Le, Richard G. Fessler, David O. Okonkwo, Adam S. Kanter, Neel Anand, Dean Chou, Kai-Ming G. Fu, Alexander F. Haddad, Christopher I. Shaffrey, Gregory M. Mundis Jr. and the International Spine Study Group

), pelvic incidence (PI), PT, and PI-LL mismatch. The TPA is an alternative method to assess global sagittal alignment that accounts for pelvic compensation and is an angle defined by a line drawn from the center of T1 to the bifemoral heads and a line drawn from the bifemoral heads to the mid-S1 endplate. 6 Unlike SVA, it is an angular measurement, so calibration is not needed. All imaging was reviewed at a single site (Hospital for Special Surgery, New York, New York) for uniformity, and calculations were performed using specialized software (SpineView, ENSAM ParisTech