Sagittal alignment of the cervical spine in the setting of adolescent idiopathic scoliosis

Restricted access

OBJECTIVE

The goal of this study was to investigate the impact of thoracic and lumbar alignment on cervical alignment in patients with adolescent idiopathic scoliosis (AIS).

METHODS

Eighty-one patients with AIS who had a Cobb angle > 40° and full-length spine radiographs were included. Radiographs were analyzed using dedicated software to measure pelvic parameters (sacral slope [SS], pelvic incidence [PI], pelvic tilt [PT]); regional parameters (C1 slope, C0–C2 angle, chin-brow vertical angle [CBVA], slope of line of sight [SLS], McRae slope, McGregor slope [MGS], C2–7 [cervical lordosis; CL], C2–7 sagittal vertical axis [SVA], C2–T3, C2–T3 SVA, C2–T1 Harrison measurement [C2–T1 Ha], T1 slope, thoracic kyphosis [TK], lumbar lordosis [LL], and PI-LL mismatch); and global parameters (SVA). Patients were stratified by their lumbar alignment into hyperlordotic (LL > 59.7°) and normolordotic (LL 39.3° to 59.7°) groups and also, based on their thoracic alignment, into hypokyphotic (TK < −33.1°) and normokyphotic (TK −33.1° to −54.9°) groups. Finally, they were grouped based on their global alignment into either an anterior-aligned group or a posterior-aligned group.

RESULTS

The lumbar hyperlordotic group, in comparison to the normolordotic group, had a significantly larger LL, SS, PI (all p < 0.001), and TK (p = 0.014) and a significantly smaller PI-LL mismatch (p = 0.001). Lumbar lordosis had no influence on local cervical parameters.

The thoracic hypokyphotic group had a significantly larger PI-LL mismatch (p < 0.002) and smaller T1 slope (p < 0.001), and was significantly more posteriorly aligned than the normokyphotic group (−15.02 ± 8.04 vs 13.54 ± 6.17 [mean ± SEM], p = 0.006). The patients with hypokyphotic AIS had a kyphotic cervical spine (cervical kyphosis [CK]) (p < 0.001). Furthermore, a posterior-aligned cervical spine in terms of C2–7 SVA (p < 0.006) and C2–T3 SVA (p < 0.001) was observed in the thoracic hypokyphotic group.

Comparing patients in terms of global alignment, the posterior-aligned group had a significantly smaller T1 slope (p < 0.001), without any difference in terms of pelvic, lumbar, and thoracic parameters when compared to the anterior-aligned group. The posterior-aligned group also had a CK (−9.20 ± 1.91 vs 5.21 ± 2.95 [mean ± SEM], p < 0.001) and a more posterior-aligned cervical spine, as measured by C2–7 SVA (p = 0.003) and C2–T3 SVA (p < 0.001).

CONCLUSIONS

Alignment of the cervical spine is closely related to thoracic curvature and global alignment. In patients with AIS, a hypokyphotic thoracic alignment or posterior global alignment was associated with a global cervical kyphosis. Interestingly, upper cervical and cranial parameters were not statistically different in all investigated groups, meaning that the upper cervical spine was not recruited for compensation in order to maintain a horizontal gaze.

ABBREVIATIONS AIS = adolescent idiopathic scoliosis; CBVA = chin-brow vertical angle; CK = cervical kyphosis; CL = cervical lordosis; C2–T1 Ha = C2–T1 Harrison measurement; LL = lumbar lordosis; MGS = McGregor slope; PI = pelvic incidence; PT = pelvic tilt; SLS = slope of line of sight; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis.

Article Information

Correspondence Wojciech Pepke: Heidelberg University Hospital, Heidelberg, Germany. wojciech.pepke@med.uni-heidelberg.de.

INCLUDE WHEN CITING Published online August 24, 2018; DOI: 10.3171/2018.3.SPINE171263.

Disclosures Dr. V. Lafage owns stock in Nemaris, Inc. She receives support for non–study-related clinical or research effort that she oversees from SRS, NASS (grants), DePuy Spine, K2M, Stryker, and NuVasive (NuVasive funds paid through ISSGF). She is a consultant for NuVasive and has speaking and/or teaching arrangements with AOSpine and DePuy Spine. Dr. Schwab owns stock in Nemaris, Inc. He receives support for non–study-related clinical or research effort that he oversees from DePuy Spine, NuVasive, Stryker, and K2M. He is a consultant for MSD, Zimmer-Biomet, Medicrea, NuVasive, and K2M. He has speaking and/or teaching arrangements with MSD, Zimmer-Biomet, Medicrea, NuVasive, and K2M.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Radiographs of the spine overlaid with schematic presentation of horizontal gaze, upper cervical, lower cervical, thoracic, lumbar, and spinopelvic parameters. Horizontal gaze: CBVA, SLS, McRae slope, and MGS. Upper cervical: C0 slope, C1 slope, C2 slope, and C0–C2 angle. Lower cervical: C2–7, C2–7 SVA, C2–T3, C2–T3 SVA, and C2–T1 Ha. Thoracic: T1 slope and TK. Lumbar: LL. Global alignment: SVA. Figure is available in color online only.

  • View in gallery

    Bar graphs with the sum of posterior tangents for cervical segments (A, expressed as angle [°]) and segmental cervical slip (B, expressed in millimeters [mm]) measured according to LL; only the C4–5 segment revealed a significant slip (red box). Negative value denotes cervical kyphosis. Figure is available in color online only.

  • View in gallery

    Bar graph with comparison of cervical parameters C2–7, C2–T3, and C2–T1 between subgroups: thoracic hypokyphosis versus normokyphosis (negative value denotes CK). Data expressed as angle (°). Figure is available in color online only.

  • View in gallery

    Bar graph with comparison of cervical C2–7 SVA and C2–T3 SVA between subgroups: thoracic hypokyphosis versus normokyphosis. Data expressed in millimeters (mm). Figure is available in color online only.

  • View in gallery

    Bar graphs with sum of posterior tangents for cervical segments (A, expressed as angle [°]) and segmental cervical slip (B, expressed in millimeters [mm]) measured according to TK. A cervical segmental slip of the lower cervical spine was noted (red boxes). Negative value denotes CK. Figure is available in color online only.

  • View in gallery

    Bar graph with comparison of cervical parameters C2–7, C2–T3, C2–T1, C2–7 SVA, and C2–T3 SVA between subgroups: anteriorly aligned versus posteriorly aligned (negative value denotes CK). Data for cervical parameters expressed as angle (°) and SVA expressed in millimeters (mm). Figure is available in color online only.

  • View in gallery

    Bar graphs with sum of posterior tangents for cervical segments (A, expressed as angle [°]) and segmental cervical slip (B, expressed in millimeters [mm]) measured according to global alignment. A cervical sagittal slip in two segments (C3–4, C5–6) was observed (red boxes). Negative value denotes CK. Figure is available in color online only.

References

  • 1

    Aykac BAyhan SYuksel SGuler UOPellise FAlanay A: Sagittal alignment of cervical spine in adult idiopathic scoliosis. Eur Spine J 24:117511822015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bridwell KHBetz RCapelli AMHuss GHarvey C: Sagittal plane analysis in idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation. Spine (Phila Pa 1976) 15:9219261990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Canavese FTurcot KDe Rosa Vde Coulon GKaelin A: Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Eur Spine J 20:114111482011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Charles YPSfeir GMatter-Parrat VSauleau EASteib JP: Cervical sagittal alignment in idiopathic scoliosis treated by posterior instrumentation and in situ bending. Spine (Phila Pa 1976) 40:E419E4272015

    • Search Google Scholar
    • Export Citation
  • 5

    Cochran TIrstam LNachemson A: Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion. Spine (Phila Pa 1976) 8:5765841983

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Diebo BGChallier VHenry JKOren JHSpiegel MAVira S: Predicting cervical alignment required to maintain horizontal gaze based on global spinal alignment. Spine (Phila Pa 1976) 41:179518002016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Dubousset JCotrel Y: Application technique of Cotrel-Dubousset instrumentation for scoliosis deformities. Clin Orthop Relat Res (264):1031101991

  • 8

    Halm HCastro WHJerosch JWinkelmann W: Sagittal plane correction in “King-classified” idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation. Acta Orthop Belg 61:2943011995

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Harrison DDTroyanovich SJHarrison DEJanik TJMurphy DJ: A normal sagittal spinal configuration: a desirable clinical outcome. J Manipulative Physiol Ther 19:3984051996

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Harrison DEHarrison DDCailliet RTroyanovich SJJanik TJHolland B: Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine (Phila Pa 1976) 25:207220782000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hilibrand ASTannenbaum DAGraziano GPLoder RTHensinger RN: The sagittal alignment of the cervical spine in adolescent idiopathic scoliosis. J Pediatr Orthop 15:6276321995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Hiyama ASakai DWatanabe MKatoh HSato MMochida J: Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis: a comparative study of 42 adolescents with idiopathic scoliosis and 24 normal adolescents. Eur Spine J 25:322632332016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Ilharreborde BVidal CSkalli WMazda K: Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis treated by posteromedial translation. Eur Spine J 22:3303372013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Ito KImagama SIto ZAndo KKobayashi KHida T: Analysis of cervical kyphosis and spinal balance in young idiopathic scoliosis patients classified by the apex of thoracic kyphosis. Eur Spine J 25:322032252016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Katsuura AHukuda SSaruhashi YMori K: Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J 10:3203242001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kojima TKurokawa T: Quantitation of three-dimensional deformity of idiopathic scoliosis. Spine (Phila Pa 1976) 17 (3 Suppl):S22S291992

    • Search Google Scholar
    • Export Citation
  • 17

    Labelle HDansereau JBellefleur Cde Guise JRivard CHPoitras B: Peroperative three-dimensional correction of idiopathic scoliosis with the Cotrel-Dubousset procedure. Spine (Phila Pa 1976) 20:140614091995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Le Huec JCDemezon HAunoble S: Sagittal parameters of global cervical balance using EOS imaging: normative values from a prospective cohort of asymptomatic volunteers. Eur Spine J 24:63712015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Lee SHKim KTSeo EMSuk KSKwack YHSon ES: The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults. J Spinal Disord Tech 25:E41E472012

    • Search Google Scholar
    • Export Citation
  • 20

    Lee SHSon ESSeo EMSuk KSKim KT: Factors determining cervical spine sagittal balance in asymptomatic adults: correlation with spinopelvic balance and thoracic inlet alignment. Spine J 15:7057122015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Lippa LLippa LCacciola F: Loss of cervical lordosis: What is the prognosis? J Craniovertebr Junction Spine 8:9142017

  • 22

    Mac-Thiong JMLabelle HBerthonnaud EBetz RRRoussouly P: Sagittal spinopelvic balance in normal children and adolescents. Eur Spine J 16:2272342007

  • 23

    Mac-Thiong JMLabelle HCharlebois MHuot MPde Guise JA: Sagittal plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal curve type. Spine (Phila Pa 1976) 28:140414092003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Negrini SAulisa AGAulisa LCirco ABde Mauroy JCDurmala J: 2011 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 7:32012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Norheim EPCarreon LYSucato DJLenke LGGlassman SD: Cervical spine compensation in adolescent idiopathic scoliosis. Spine Deform 3:3273312015

  • 26

    Scheer JKTang JASmith JSAcosta FL JrProtopsaltis TSBlondel B: Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 19:1411592013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Shah SADhawale AAOda JEYorgova PNeiss GIHolmes L Jr: Ponte osteotomies with pedicle screw instrumentation in the treatment of adolescent idiopathic scoliosis. Spine Deform 1:1962042013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Stokes IABigalow LCMoreland MS: Three-dimensional spinal curvature in idiopathic scoliosis. J Orthop Res 5:1021131987

  • 29

    Tang JAScheer JKSmith JSDeviren VBess SHart RA: The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 76 (Suppl 1):S14S212015

    • Search Google Scholar
    • Export Citation
  • 30

    Wang LLiu X: Cervical sagittal alignment in adolescent idiopathic scoliosis patients (Lenke type 1–6). J Orthop Sci 22:2542592017

  • 31

    Yukawa YKato FSuda KYamagata MUeta TYoshida M: Normative data for parameters of sagittal spinal alignment in healthy subjects: an analysis of gender specific differences and changes with aging in 626 asymptomatic individuals. Eur Spine J 27:4264322018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 417 417 20
Full Text Views 221 221 2
PDF Downloads 273 273 11
EPUB Downloads 0 0 0

PubMed

Google Scholar