Surgical outcomes in rigid versus flexible cervical deformities

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  • 1 Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York;
  • 2 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • 3 Department of Orthopedic Surgery, University of Calgary, Alberta, Canada;
  • 4 Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;
  • 5 Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Providence, Rhode Island;
  • 6 San Diego Center for Spinal Disorders, La Jolla, California;
  • 7 Department of Orthopaedic Surgery, University of California, Davis, California;
  • 8 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
  • 9 Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri;
  • 10 Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington;
  • 11 Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas;
  • 12 Denver International Spine Clinic, Presbyterian St. Luke’s Medical Center, Rocky Mountain Hospital for Children, Denver, Colorado; and
  • 13 Department of Neurological Surgery, University of California, San Francisco, California
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OBJECTIVE

Cervical deformity (CD) patients have severe disability and poor health status. However, little is known about how patients with rigid CD compare with those with flexible CD. The main objectives of this study were to 1) assess whether patients with rigid CD have worse baseline alignment and therefore require more aggressive surgical corrections and 2) determine whether patients with rigid CD have similar postoperative outcomes as those with flexible CD.

METHODS

This is a retrospective review of a prospective, multicenter CD database. Rigid CD was defined as cervical lordosis (CL) change < 10° between flexion and extension radiographs, and flexible CD was defined as a CL change ≥ 10°. Patients with rigid CD were compared with those with flexible CD in terms of cervical alignment and health-related quality of life (HRQOL) at baseline and at multiple postoperative time points. The patients were also compared in terms of surgical and intraoperative factors such as operative time, blood loss, and number of levels fused.

RESULTS

A total of 127 patients met inclusion criteria (32 with rigid and 95 with flexible CD, 63.4% of whom were females; mean age 60.8 years; mean BMI 27.4); 47.2% of cases were revisions. Rigid CD was associated with worse preoperative alignment in terms of T1 slope minus CL, T1 slope, C2–7 sagittal vertical axis (cSVA), and C2 slope (C2S; all p < 0.05). Postoperatively, patients with rigid CD had an increased mean C2S (29.1° vs 22.2°) at 3 months and increased cSVA (47.1 mm vs 37.5 mm) at 1 year (p < 0.05) compared with those with flexible CD. Patients with rigid CD had more posterior levels fused (9.5 vs 6.3), fewer anterior levels fused (1 vs 2.0), greater blood loss (1036.7 mL vs 698.5 mL), more 3-column osteotomies (40.6% vs 12.6%), greater total osteotomy grade (6.5 vs 4.5), and mean osteotomy grade per level (3.3 vs 2.1) (p < 0.05 for all). There were no significant differences in baseline HRQOL scores, the rate of distal junctional kyphosis, or major/minor complications between patients with rigid and flexible CD. Both rigid and flexible CD patients reported significant improvements from baseline to 1 year according to the numeric rating scale for the neck (−2.4 and −2.7, respectively), Neck Disability Index (−8.4 and −13.3, respectively), modified Japanese Orthopaedic Association score (0.1 and 0.6), and EQ-5D (0.01 and 0.05) (p < 0.05). However, HRQOL changes from baseline to 1 year did not differ between rigid and flexible CD patients.

CONCLUSIONS

Patients with rigid CD have worse baseline cervical malalignment compared with those with flexible CD but do not significantly differ in terms of baseline disability. Rigid CD was associated with more invasive surgery and more aggressive corrections, resulting in increased operative time and blood loss. Despite more extensive surgeries, rigid CD patients had equivalent improvements in HRQOL compared with flexible CD patients. This study quantifies the importance of analyzing flexion-extension images, creating a prognostic tool for surgeons planning CD correction, and counseling patients who are considering CD surgery.

ABBREVIATIONS CBVA = chin-brow vertical angle; CD = cervical deformity; CL = cervical lordosis; cSVA = C2–7 sagittal vertical axis; C2S = C2 slope; DJK = distal junctional kyphosis; HRQOL = health-related quality of life; NDI = Neck Disability Index; NRS = numeric rating scale; T1S = T1 slope; T1S-CL = T1S minus CL; 3CO = 3-column osteotomy.

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Contributor Notes

Correspondence Themistocles S. Protopsaltis: NYU Langone Medical Center, New York, NY. themistocles.protopsaltis@nyulangone.org.

INCLUDE WHEN CITING Published online February 12, 2021; DOI: 10.3171/2020.8.SPINE191185.

Disclosures Dr. Protopsaltis: consultant for Globus, Stryker K2M, Innovasis, Medicrea, SpineAlign, Torus Medical, Medtronic, and NuVasive; and research support from CSRS. Dr. Smith: consultant for NuVasive, Zimmer Biomet, Stryker, DePuy Synthes, Cerapedics, and Carlsmed; direct stock ownership in Alphatec and NuVasive; editorial board member of Journal of Neurosurgery Spine, Neurosurgery, Operative Neurosurgery, Spine Deformity, and Neurospine; member of Executive Committee of the International Spine Study Group Foundation and Board of Directors for the Scoliosis Research Society; research support from DePuy Synthes; royalties from Zimmer Biomet, NuVasive, and Thieme; fellowship funding from AO Spine; and non–study-related research support from DePuy Synthes and AO Spine. Mr. R. Lafage: ownership in Nemaris. Dr. Daniels: consultant for Medtronic, OrthoFix, Spineart, Southern Spine, and Stryker; research support for the study described from Orthofix. Dr. Kim: royalties from K2M-Stryker and Zimmer Biomet; research support from ISSGF; and fellowship from AO Spine. Dr. Passias: consultant for Medicrea and SpineWave; research support from CSRS; paid presenter/speaker for Zimmer Biomet and Globus Medical; and support of non–study-related clinical or research effort from Allosource. Dr. Mundis: consultant for NuVasive, Carlsmed, Viseon, and SeaSpine; direct stock ownership in NuVasive, Alphatec, and SeaSpine; patent holder with NuVasive and K2M; royalties from K2M and NuVasive; speaker for NuVasive; and research support from ISSGF. Dr. Klineberg: consultant for Allosource, DePuy Synthes, Medicrea/Medtronic, Springer, Stryker, and Trevena; speaker for AO Spine and K2M; research support from AO Spine, DePuy, and OREF; and AO Spine fellowship grant and honoraria. Dr. Hamilton: board member of ESJ and research support from NuVasive and Pfizer. Dr. Gupta: consultant for Medtronic and DePuy; royalties from DePuy and Innomed; speaker for DePuy; board member of ESJ, Global Spine Journal, and Spine Deformity; stock options in Johnson & Johnson and Procter & Gamble; travel support from DePuy, Mizuho, Medicrea, Scoliosis Research Society, and Medtronic; honorarium and grant paid directly to institution for fellowship from AO Spine; and advisory board for DePuy and Medtronic. Dr. V. Lafage: speaker for DePuy and K2M; consultant for Globus Medical and Medtronic; royalties from NuVasive; honoraria from The Permanente Medical Group and DePuy Synthes; research support from Medtronic, NuVasive, Stryker, and DePuy Synthes; board member of ISSG and SRS; and stock ownership in Nemaris. Dr. Hart: board member of AOA, CSRS, ISSG, ISSLS, NASS, SRS, and WOA; consultant for DePuy, Globus, Orthofix, and Medtronic; speaker for DePuy, Globus, and Orthofix; royalties from DePuy, Globus, and SeaSpine; research support from DePuy and Misonix; and grant from ISSLS. Dr. Schwab: royalties from Medtronic, Zimmer Biomet, and Medicrea; consultant for Globus Medical and Zimmer Biomet; and executive committee for ISSGF. Dr. Burton: consulting/speaking for DePuy Synthes; royalties from DePuy Synthes; research support from Bioventus, DePuy, and Pfizer; direct stock ownership in Progenerative Medical; and board member of SRS and Spine Deformity. Dr. Bess: consultant for K2M and Stryker; patent holder with K2M; research support from ISSGF; research support for the study described from DePuy Synthes; and support of non–study-related clinical or research effort from Medtronic, NuVasive, K2M, Stryker, Globus Medical, SI Bone, and ISSGF. Dr. Shaffrey: consultant for Medtronic, NuVasive, SI Bone, and Siemens; direct stock ownership in NuVasive; and patent holder with NuVasive, Medtronic, and Zimmer Biomet. Dr. Ames: employee of UCSF; royalties from Biomet Spine, DePuy, Next Orthosurgical, NuVasive, Stryker, K2M, and Medicrea; and consultant for DePuy, K2M, Medicrea, Medtronic, Stryker, and Zimmer Biomet.

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