Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up

Elias EliasDepartment of Neurosurgery, University of Virginia, Charlottesville, Virginia;

Search for other papers by Elias Elias in
jns
Google Scholar
PubMed
Close
 MD, MPH, MSc
,
Shay BessPresbyterian St. Luke’s Medical Center, Denver, Colorado;

Search for other papers by Shay Bess in
jns
Google Scholar
PubMed
Close
 MD
,
Breton G. LinePresbyterian St. Luke’s Medical Center, Denver, Colorado;

Search for other papers by Breton G. Line in
jns
Google Scholar
PubMed
Close
 BSME
,
Virginie LafageDepartment of Orthopedic Surgery, Lennox Hill Hospital, New York, New York;

Search for other papers by Virginie Lafage in
jns
Google Scholar
PubMed
Close
 PhD
,
Renaud LafageDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

Search for other papers by Renaud Lafage in
jns
Google Scholar
PubMed
Close
 MS
,
Eric KlinebergDepartment of Orthopaedic Surgery, University of California, Davis, Sacramento, California;

Search for other papers by Eric Klineberg in
jns
Google Scholar
PubMed
Close
 MD
,
Han Jo KimDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

Search for other papers by Han Jo Kim in
jns
Google Scholar
PubMed
Close
 MD
,
Peter PassiasDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Peter Passias in
jns
Google Scholar
PubMed
Close
 MD
,
Zeina NasserNeuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon;

Search for other papers by Zeina Nasser in
jns
Google Scholar
PubMed
Close
 MSc, PhD
,
Jeffrey L. GumLeatherman Spine Center, Louisville, Kentucky;

Search for other papers by Jeffrey L. Gum in
jns
Google Scholar
PubMed
Close
 MD
,
Khaled KebaishDepartment of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland;

Search for other papers by Khaled Kebaish in
jns
Google Scholar
PubMed
Close
 MD
,
Robert EastlackScripps Clinic, San Diego, California;

Search for other papers by Robert Eastlack in
jns
Google Scholar
PubMed
Close
 MD
,
Alan H. DanielsDepartment of Orthopedic Surgery, Brown University, Providence, Rhode Island;

Search for other papers by Alan H. Daniels in
jns
Google Scholar
PubMed
Close
 MD
,
Gregory Mundis Jr.Scripps Clinic, San Diego, California;

Search for other papers by Gregory Mundis Jr. in
jns
Google Scholar
PubMed
Close
 MD
,
Richard HostinDepartment of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas;

Search for other papers by Richard Hostin in
jns
Google Scholar
PubMed
Close
 MD
,
Themistocles S. ProtopsaltisDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Themistocles S. Protopsaltis in
jns
Google Scholar
PubMed
Close
 MD
,
Alex SoroceanuDepartment of Orthopedic Surgery, University of Calgary, Alberta, Canada;

Search for other papers by Alex Soroceanu in
jns
Google Scholar
PubMed
Close
 MD
,
D. Kojo HamiltonDepartment of Neurosurgery, University of Pittsburgh, Pennsylvania;

Search for other papers by D. Kojo Hamilton in
jns
Google Scholar
PubMed
Close
 MD
,
Michael P. KellyDepartment of Orthopedic Surgery, Rady Children’s Hospital, San Diego, California;

Search for other papers by Michael P. Kelly in
jns
Google Scholar
PubMed
Close
 MD
,
Munish GuptaDepartment of Orthopedic Surgery, Washington University, St. Louis, Missouri;

Search for other papers by Munish Gupta in
jns
Google Scholar
PubMed
Close
 MD
,
Robert HartDepartment of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington;

Search for other papers by Robert Hart in
jns
Google Scholar
PubMed
Close
 MD
,
Frank J. SchwabDepartment of Orthopedic Surgery, Lennox Hill Hospital, New York, New York;

Search for other papers by Frank J. Schwab in
jns
Google Scholar
PubMed
Close
 MD
,
Douglas BurtonDepartment of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

Search for other papers by Douglas Burton in
jns
Google Scholar
PubMed
Close
 MD
,
Christopher P. AmesDepartment of Neurological Surgery, University of California, San Francisco, California; and

Search for other papers by Christopher P. Ames in
jns
Google Scholar
PubMed
Close
 MD
,
Christopher I. ShaffreyDepartments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina

Search for other papers by Christopher I. Shaffrey in
jns
Google Scholar
PubMed
Close
 MD
,
Justin S. SmithDepartment of Neurosurgery, University of Virginia, Charlottesville, Virginia;

Search for other papers by Justin S. Smith in
jns
Google Scholar
PubMed
Close
 MD, PhD
, and
on behalf of International Spine Study Group
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $384.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $624.00
USD  $45.00
USD  $384.00
USD  $624.00
Print or Print + Online Sign in

OBJECTIVE

Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery.

METHODS

A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up.

RESULTS

Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2–8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up.

CONCLUSIONS

This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors’ knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.

ABBREVIATIONS

ACD = adult cervical deformity; CSM = cervical spondylotic myelopathy; DJK = distal junctional kyphosis; EQ-5D = EuroQol-5D; HRQL = health-related quality of life; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PROMs = patient-reported outcome measures; VAS = visual analog scale; VCR = vertebral column resection; 3CO = 3-column osteotomy.
  • Collapse
  • Expand

Illustrations from Hagan et al. (pp 843–850). © Albert Telfeian, published with permission.

  • 1

    Passias PG, Horn SR, Soroceanu A, et al. Development of a novel cervical deformity surgical invasiveness index. Spine (Phila Pa 1976). 2020;45(2):116123.

  • 2

    Smith JS, Line B, Bess S, et al. The health impact of adult cervical deformity in patients presenting for surgical treatment: comparison to United States population norms and chronic disease states based on the EuroQuol-5 Dimensions questionnaire. Neurosurgery. 2017;80(5):716725.

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

    Passias PG, Soroceanu A, Smith J, et al. Postoperative cervical deformity in 215 thoracolumbar patients with adult spinal deformity: prevalence, risk factors, and impact on patient-reported outcome and satisfaction at 2-year follow-up. Spine (Phila Pa 1976). 2015;40(5):283291.

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

    Albayrak I, Bağcacı S, Sallı A, Kucuksen S, Uğurlu H. A rare cause of dysphagia: compression of the esophagus by an anterior cervical osteophyte due to ankylosing spondylitis. Korean J Intern Med (Korean Assoc Intern Med). 2013;28(5):614618.

    • Search Google Scholar
    • Export Citation
  • 5

    Lee JS, Youn MS, Shin JK, Goh TS, Kang SS. Relationship between cervical sagittal alignment and quality of life in ankylosing spondylitis. Eur Spine J. 2015;24(6):11991203.

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

    Moore RE, Dormans JP, Drummond DS, Shore EM, Kaplan FS, Auerbach JD. Chin-on-chest deformity in patients with fibrodysplasia ossificans progressiva. A case series. J Bone Joint Surg Am. 2009;91(6):14971502.

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

    Simmons EH. The surgical correction of flexion deformity of the cervical spine in ankylosing spondylitis. Clin Orthop Relat Res. 1972;86(86):132143.

  • 8

    Urist MR. Osteotomy of the cervical spine; report of a case of ankylosing rheumatoid spondylitis. J Bone Joint Surg Am. 1958;40-A(4):833843.

  • 9

    Ames CP, Smith JS, Scheer JK, et al. A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction: clinical article. J Neurosurg Spine. 2013;19(3):269278.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Smith JS, Klineberg E, Shaffrey CI, et al. Assessment of surgical treatment strategies for moderate to severe cervical spinal deformity reveals marked variation in approaches, osteotomies, and fusion levels. World Neurosurg. 2016;91:228237.

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

    Nottmeier EW, Deen HG, Patel N, Birch B. Cervical kyphotic deformity correction using 360-degree reconstruction. J Spinal Disord Tech. 2009;22(6):385391.

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

    Deviren V, Scheer JK, Ames CP. Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases. J Neurosurg Spine. 2011;15(2):174181.

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

    Grosso MJ, Hwang R, Mroz T, Benzel E, Steinmetz MP. Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery. J Neurosurg Spine. 2013;18(6):537544.

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

    Uchida K, Nakajima H, Sato R, et al. Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression. J Neurosurg Spine. 2009;11(5):521528.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Shamji MF, Ames CP, Smith JS, Rhee JM, Chapman JR, Fehlings MG. Myelopathy and spinal deformity: relevance of spinal alignment in planning surgical intervention for degenerative cervical myelopathy. Spine (Phila Pa 1976). 2013;38(22 Suppl 1):S147S148.

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

    Etame AB, Wang AC, Than KD, La Marca F, Park P. Outcomes after surgery for cervical spine deformity: review of the literature. Neurosurg Focus. 2010;28(3):E14.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Grosso MJ, Hwang R, Krishnaney AA, Mroz TE, Benzel EC, Steinmetz MP. Complications and outcomes for surgical approaches to cervical kyphosis. J Spinal Disord Tech. 2015;28(7):E385E393.

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

    Hann S, Chalouhi N, Madineni R, et al. An algorithmic strategy for selecting a surgical approach in cervical deformity correction. Neurosurg Focus. 2014;36(5):E5.

  • 19

    Kim HJ, Piyaskulkaew C, Riew KD. Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities. Spine (Phila Pa 1976). 2015;40(3):143146.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Scheer JK, Ames CP, Deviren V. Assessment and treatment of cervical deformity. Neurosurg Clin N Am. 2013;24(2):249274.

  • 21

    Smith JS, Lafage V, Schwab FJ, et al. Prevalence and type of cervical deformity among 470 adults with thoracolumbar deformity. Spine (Phila Pa 1976). 2014;39(17):E1001E1009.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Etame AB, Than KD, Wang AC, La Marca F, Park P. Surgical management of symptomatic cervical or cervicothoracic kyphosis due to ankylosing spondylitis. Spine (Phila Pa 1976). 2008;33(16):E559E564.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Cho SK, Safir S, Lombardi JM, Kim JS. Cervical spine deformity: indications, considerations, and surgical outcomes. J Am Acad Orthop Surg. 2019;27(12):e555e567.

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

    Ailon T, Smith JS, Shaffrey CI, et al. Outcomes of operative treatment for adult cervical deformity: a prospective multicenter assessment with 1-year follow-up. Neurosurgery. 2018;83(5):10311039.

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

    Smith JS, Ramchandran S, Lafage V, et al. Prospective multicenter assessment of early complication rates associated with adult cervical deformity surgery in 78 patients. Neurosurgery. 2016;79(3):378388.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Smith JS, Shaffrey CI, Lafage R, et al. Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients. Eur Spine J. 2017;26(8):21282137.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Smith JS, Buell TJ, Shaffrey CI, et al. Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up. J Neurosurg Spine. 2020;33(5):588600.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Klineberg EO, Wick JB, Lafage R, et al. Development and validation of a multidomain surgical complication classification system for adult spinal deformity. Spine (Phila Pa 1976). 2021;46(4):E267E273.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013;95(18):16511658.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Chavanne A, Pettigrew DB, Holtz JR, Dollin N, Kuntz C IV. Spinal cord intramedullary pressure in cervical kyphotic deformity: a cadaveric study. Spine (Phila Pa 1976). 2011;36(20):16191626.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y. Spinal kyphosis causes demyelination and neuronal loss in the spinal cord: a new model of kyphotic deformity using juvenile Japanese small game fowls. Spine (Phila Pa 1976). 2005;30(21):23882392.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Koller H, Ames C, Mehdian H, et al. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. Eur Spine J. 2019;28(2):324344.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kang DG, Holekamp TF, Wagner SC, Lehman RA Jr. Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. Spine J. 2015;15(4):762770.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Theologis AA, Demirkiran G, Callahan M, Pekmezci M, Ames C, Deviren V. Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis. Spine (Phila Pa 1976). 2014;39(22):18751880.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Peters A, Verma K, Slobodyanyuk K, et al. Antifibrinolytics reduce blood loss in adult spinal deformity surgery: a prospective, randomized controlled trial. Spine (Phila Pa 1976). 2015;40(8):E443E449.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Yuk FJ, Rasouli JJ, Arginteanu MS, et al. The case for T2 pedicle subtraction osteotomy in the surgical treatment of rigid cervicothoracic deformity. J Neurosurg Spine. 2019;32(2):248257.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Theologis AA, Tabaraee E, Funao H, et al. Three-column osteotomies of the lower cervical and upper thoracic spine: comparison of early outcomes, radiographic parameters, and peri-operative complications in 48 patients. Eur Spine J. 2015;24(suppl 1):S23S30.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Gupta S, Eksi MS, Ames CP, et al. A novel 4-rod technique offers potential to reduce rod breakage and pseudarthrosis in pedicle subtraction osteotomies for adult spinal deformity correction. Oper Neurosurg (Hagerstown). 2018;14(4):449456.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Smith JS, Shaffrey E, Klineberg E, et al. Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine. 2014;21(6):9941003.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tang JA, Leasure JM, Smith JS, Buckley JM, Kondrashov D, Ames CP. Effect of severity of rod contour on posterior rod failure in the setting of lumbar pedicle subtraction osteotomy (PSO): a biomechanical study. Neurosurgery. 2013;72(2):276283.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Cady-McCrea CI, Galgano MA. C2 quad-screws facilitate 4-rod fixation across the cervico-thoracic junction. Surg Neurol Int. 2021;12:40.

  • 42

    Godzik J, Lehrman JN, Farber SH, et al. Optimizing cervicothoracic junction biomechanics after C7 pedicle subtraction osteotomy: a cadaveric study of stability and rod strain. World Neurosurg. 2022;160:e278e287.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Smith JS, Shaffrey CI, Kim HJ, et al. Prospective multicenter assessment of all-cause mortality following surgery for adult cervical deformity. Neurosurgery. 2018;83(6):12771285.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Miller EK, Ailon T, Neuman BJ, et al. Assessment of a novel adult cervical deformity frailty index as a component of preoperative risk stratification. World Neurosurg. 2018;109:e800e806.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 2180 2180 92
Full Text Views 380 380 12
PDF Downloads 349 349 17
EPUB Downloads 0 0 0