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Susan Núñez-Pereira, Wolfgang Hitzl, Viola Bullmann, Oliver Meier and Heiko Koller


Sagittal malalignment of the cervical spine has been associated with worsened postsurgical outcomes. For better operative planning of fusion and alignment restoration, improved knowledge of ideal fusion angles and interdependences between upper and lower cervical spine alignment is needed. Because spinal and spinopelvic parameters might play a role in cervical sagittal alignment, their associations should be studied in depth.


The authors retrospectively analyzed digital lateral standing cervical radiographs of 145 patients (34 asymptomatic, 74 symptomatic; 37 surgically treated), including full-standing radiographs obtained in 45 of these patients. Sagittal measurements were as follows: C2–7, occiput (Oc)–C2, C1–2 Cobb angles, and C-7 slope (the angle between the horizontal line and the superior endplate of C-7), as well as T4–12 and L1–S1 Cobb angles, sacral slope, pelvic incidence, and C-7 sagittal vertical axis (SVA). A correlation analysis was performed, and linear regression models were developed.


Statistical analyses revealed significant correlations between C2–7 and Oc–C2 (r = −0.4, p < 0.01), Oc–C2 (r = −0.3, p < 0.01), and C1–2 angle (r = −0.3, p < 0.01). C-7 slope was significantly correlated with C2–7 (r = −0.5, p < 0.01) and with Oc–C2 angle (r = 0.2, p = 0.02). Total cervical (Oc–C7) lordosis was 30.2° and did not differ significantly among asymptomatic, symptomatic, and surgically treated patients. Correlations between C2–7 and Oc–C2 alignment were stronger in asymptomatic patients (r = –0.5, p < 0.01) and surgically treated patients (r = –0.5, p < 0.01) than in symptomatic patients (r = –0.3, p = 0.01), but the between-group difference was not significant (p > 0.1). Comparing cervical and spinopelvic alignment revealed a significant correlation between sacral slope and C-7 slope (r = –0.3, p = 0.04) and C2–7 (r = 0.4, p < 0.01). The C-7 SVA correlated significantly with the C-7 slope (r = –0.4, p < 0.01). The interdependences were stronger within the occipitocervical parameters than between the cervical and remaining spinal parameters.


Significant correlations between the upper and lower cervical spine exist, confirming the existence of inherent compensatory mechanisms to maintain overall balance; no significant differences were found among asymptomatic, symptomatic, and surgically treated patients. The C-7 slope is a useful marker of overall sagittal alignment, acting as a link between the occipitocervical and thoracolumbar spine.

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Heiko Koller, Michael Mayer, Juliane Zenner, Herbert Resch, Alfred Niederberger, Johann Fierlbeck, Wolfgang Hitzl and Frank L. Acosta Jr.


In thoracolumbar deformity surgery, anterior-only approaches are used for reconstruction of anterior column failures. It is generally advised that vertebral body replacements (VBRs) should be preloaded by compression. However, little is known regarding the impact of different techniques for generation of preloads and which surgical principle is best for restoration of lordosis. Therefore, the authors analyzed the effect of different surgical techniques to restore spinal alignment and lordosis as well as the ability to generate axial preloads on VBRs in anterior column reconstructions.


The authors performed a laboratory study using 7 fresh-frozen specimens (from T-3 to S-1) to assess the ability for lordosis reconstruction of 5 techniques and their potential for increasing preloads on a modified distractable VBR in a 1-level thoracolumbar corpectomy. The testing protocol was as follows: 1) Radiographs of specimens were obtained. 2) A 1-level corpectomy was performed. 3) In alternating order, lordosis was applied using 1 of the 5 techniques. Then, preloads during insertion and after relaxation using the modified distractable VBR were assessed using a miniature load-cell incorporated in the modified distractable VBR. The modified distractable VBR was inserted into the corpectomy defect after lordosis was applied using 1) a lamina spreader; 2) the modified distractable VBR only; 3) the ArcoFix System (an angular stable plate system enabling in situ reduction); 4) a lordosizer (a customized instrument enabling reduction while replicating the intervertebral center of rotation [COR] according to the COR method); and 5) a lordosizer and top-loading screws ([LZ+TLS], distraction with the lordosizer applied on a 5.5-mm rod linked to 2 top-loading pedicle screws inserted laterally into the vertebra). Changes in the regional kyphosis angle were assessed radiographically using the Cobb method.


The bone mineral density of specimens was 0.72 ± 22.6 g/cm2. The maximum regional kyphosis angle reconstructed among the 5 techniques averaged 9.7°−16.1°, and maximum axial preloads averaged 123.7–179.7 N. Concerning correction, in decreasing order the LZ+TLS, lordosizer, and ArcoFix System outperformed the lamina spreader and modified distractable VBR. The order of median values for insertion peak load, from highest to lowest, were lordosizer, LZ+TLS, and ArcoFix, which outperformed the lamina spreader and modified distractable VBR. In decreasing order, the axial preload was highest with the lordosizer and LZ+TLS, which both outperformed the lamina spreader and the modified distractable VBR. The technique enabling the greatest lordosis achieved the highest preloads. With the ArcoFix System and LZ+TLS, compression loads could be applied and were 247.8 and 190.6 N, respectively, which is significantly higher than the insertion peak load and axial preload (p < 0.05).


Including the ability for replication of the COR in instruments designed for anterior column reconstructions, the ability for lordosis restoration of the anterior column and axial preloads can increase, which in turn might foster fusion.

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Martine W. T. van Bilsen, Christopher Ullrich, Luis Ferraris, Axel Hempfing, Wolfgang Hitzl, Michael Mayer and Heiko Koller


Computed tomography (CT) scans are accepted as the imaging standard of reference to define union after anterior cervical discectomy and fusion (ACDF). However, ideal CT criteria to diagnose union have not been identified or validated. The objective of this study was to analyze the diagnostic value of 9 CT-based criteria and identify the ideal criteria among them to assess cervical fusion after ACDF using surgical exploration as the standard of reference.


The authors performed a retrospective radiographic study of a single surgeon’s prospective assessment of osseous fusion during cervical revision surgery by analyzing complete radiographic data in 44 patients who underwent anterior cervical revision surgery due to symptomatic suspected nonunion or adjacent level disease. All patients received standard preoperative CT scans, which were assessed by an independent radiologist to evaluate 9 diagnostic criteria for osseous union. During revision surgery, scar tissue was removed and manual segmental translation tests were performed. Nonunion was defined by visualized motion at the treated ACDF level.


In total, 44 patients were included in the study (30 men; patient age 54 ± 6 years, BMI 28 ± 5 kg/m2). For analysis of fusion, 75 cervical levels were explored, of which 61 levels (81%) showed intraoperative movement indicating nonunion. Statistical analysis showed that of the 9 parameters used to diagnose bone union, “bridging bone on ≥ 3 CT slices” yielded the highest sensitivity (100%) and specificity (58%). Multivariate analysis revealed that prediction accuracy was not increased if several criteria were combined to determine fusion.


The authors found that the best indicator of bone union was the item bridging bone on ≥ 3 CT slices. Combining the scoring of more than one criterion did not increase the diagnostic accuracy.