C2 versus C3 or C4 as the upper instrumented vertebra for long-segment cervical fusions: a systematic review and meta-analysis

Presented at the 2023 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Esteban Quiceno Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Amna Hussein Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Annie Pico Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Ebtesam Abdulla Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Isabel L. Bauer Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Kristin Nosova Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Jose Orenday-Barraza Department of Surgery, University of Minnesota, Minneapolis, Minnesota

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Alexandros Moniakis Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Monis Ahmed Khan Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Michael Prim Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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Ali A. Baaj Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona; and

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OBJECTIVE

Selecting C2 versus C3 or C4 (i.e., C3/C4) as the rostral anchoring level in long-segment cervical fusions is a common clinical conundrum. The data regarding proximal failure in long constructs of the cervical spine is scarce. The objective of this study was to systematically review the published literature and perform a meta-analysis of the incidence for proximal adjacent-segment disease (ASD) in the context of long cervical fusions and cervicothoracic fusions ending in C2 versus those ending in the subaxial spine (C3 or C4).

METHODS

Using the PRISMA guidelines, the authors performed a search of the PubMed/MEDLINE, Embase/Ovid, and Cochrane Central databases to identify all full-text articles in the English-language literature with the following inclusion criteria: 1) studies including patients with the upper instrumented vertebra (UIV) at C2 versus C3/C4; 2) patients undergoing ≥ 3-level posterior cervical fusion; and 3) indication for surgery of degenerative disc disease, cervical spondylotic myelopathy, or cervical deformity. Studies that were not published in the English language, case reports, review articles, letters to the editor, and meeting abstracts were excluded. A meta-analysis was conducted using a fixed-effects model when I2 values were below 70%. Conversely, when I2 values were equal to or greater than 70%, a random-effects model was used. A funnel plot was used to assess the presence of publication bias.

RESULTS

Seven studies consisting of 1215 patients were included in the meta-analysis. There were 403 (32.8%) patients in the C2 UIV group and 812 (67.2%) patients in the C3/C4 UIV group. When the 7 studies were analyzed, the overall rate of reoperation was comparable between the C2 (9.2%) and C3/C4 (9.4%) UIV groups (p = 0.93) but the rate of surgical ASD due to proximal pathology was 1.2% and 3%, respectively (OR 0.36, 95% CI 0.15–0.86; p = 0.02). When comparing between groups, no statistical difference was found regarding the rate of reoperation due to distal pathology or surgical infection.

CONCLUSIONS

Long-segment cervical or cervicothoracic constructs that anchor into C2 may have similar complication rates but lower revision rates for proximal ASD than constructs that anchor into the subaxial spine.

ABBREVIATIONS

ASD = adjacent-segment disease; LIV = lower instrumented vertebra; MD = mean difference; PCF = posterior cervical fusion; PJF = proximal junctional failure; PJK = proximal junctional kyphosis; PRO = patient-reported outcome; SVA = sagittal vertical axis; UIV = upper instrumented vertebra.

Supplementary Materials

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Images from Özer and Demirtaş (pp 351–358).
  • 1

    Wei Z, Yang S, Zhang Y, Ye J, Chu TW. Prevalence and risk factors for cervical adjacent segment disease and analysis of the clinical effect of revision surgery: a minimum of 5 years’ follow-up. Global Spine J. Published online July 8, 2023. doi:10.1177/21925682231185332

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81(4):519528.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004;4(6 suppl):190S194S.

  • 4

    Virk SS, Niedermeier S, Yu E, Khan SN. Adjacent segment disease. Orthopedics. 2014;37(8):547555.

  • 5

    Uddanapalli SS. New classification for clinically symptomatic adjacent segment pathology in cervical disc disease. Asian Spine J. 2015;9(6):942951.

  • 6

    Kong L, Cao J, Wang L, Shen Y. Prevalence of adjacent segment disease following cervical spine surgery: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4171.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Park MS, Ju YS, Moon SH, et al. Reoperation rates after surgery for degenerative cervical spine disease according to different surgical procedures: national population-based cohort study. Spine (Phila Pa 1976). 2016;41(19):14841492.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Anandjiwala J, Seo JY, Ha KY, Oh IS, Shin DC. Adjacent segment degeneration after instrumented posterolateral lumbar fusion: a prospective cohort study with a minimum five-year follow-up. Eur Spine J. 2011;20(11):19511960.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Guppy KH, Royse KE, Fennessy J, Norheim EP, Harris JE, Brara HS. No difference in reoperation rates for adjacent segment disease (operative adjacent segment disease) in posterior cervical fusions stopping at C7 versus T1/T2: a cohort of 875 patients—part 1. Spine (Phila Pa 1976). 2022;47(3):261-268.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Goyal A, Akhras A, Wahood W, Alvi MA, Nassr A, Bydon M. Should multilevel posterior cervical fusions involving C7 cross the cervicothoracic junction? A systematic review and meta-analysis. World Neurosurg. 2019;127:588595.e5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Coban D, Faloon M, Changoor S, et al. Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature. J Neurosurg Spine. 2022;37(2):166174.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chang MC, Kim GU, Choo YJ, Lee GW. To cross or not to cross the cervicothoracic junction in multilevel posterior cervical fusion: a systematic review and meta-analysis. Spine J. 2022;22(5):723731.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Yang H, Huang J, Hai Y, et al. Is it necessary to cross the cervicothoracic junction in posterior cervical decompression and fusion for multilevel degenerative cervical spine disease? A systematic review and meta-analysis. J Clin Med. 2023;12(8):2806.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Scholz C, Klingler JH, Masalha W, et al. Long-term results after multilevel fusion of the cervical spine and the cervicothoracic junction: to bridge or not to bridge? World Neurosurg. 2021;148:e556e564.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Vickery JW, Varas EE, Abtahi AM. Crossing the cervicothoracic junction: a review of the current literature. Clin Spine Surg. 2022;35(10):451457.

  • 16

    Lopez AJ, Scheer JK, Leibl KE, Smith ZA, Dlouhy BJ, Dahdaleh NS. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus. 2015;38(4):E2.

  • 17

    Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

  • 18

    Pinter ZW, Karamian B, Bou Monsef J, et al. Cervical alignment and proximal and distal junctional failure in posterior cervical fusion: a multicenter comparison of 2 surgical approaches. Clin Spine Surg. 2022;35(5):E451E456.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Passias PG, Vasquez-Montes D, Poorman GW, et al. Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J. 2018;18(12):21872194.

  • 20

    Xia Y, Xu R, Kosztowski TA, et al. Reoperation for proximal adjacent segment pathology in posterior cervical fusion constructs that fuse to C2 vs C3. Neurosurgery. 2019;85(3):E520E526.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Roth SG, Khan I, Chotai S, et al. Is it better to stop at C2 or C3/4 in elective posterior cervical decompression and fusion? Spine (Phila Pa 1976). 2022;47(7):565573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Algarni N, Dea N, Evaniew N, et al. Does ending a posterior construct proximally at C2 versus C3 impact patient reported outcomes in degenerative cervical myelopathy patients up to 24 months after the surgery? Global Spine J. Published online March 24, 2023. doi:10.1177/21925682231166605

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Passias PG, Bortz CA, Segreto F, et al. Limited morbidity and possible radiographic benefit of C2 vs. subaxial cervical upper-most instrumented vertebrae. J Spine Surg. 2019;5(2):236244.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Couch BK, Patel SS, Talentino SE, et al. To cross the cervicothoracic junction? Terminating posterior cervical fusion constructs proximal to the cervicothoracic junction does not impart increased risk of reoperation in patients with cervical spondylotic myelopathy. Global Spine J. 2023;13(8):23792386.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Fayed I, Toscano DT, Triano MJ, et al. Crossing the cervicothoracic junction during posterior cervical decompression and fusion: is it necessary? Neurosurgery. 2020;86(6):E544E550.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Jones EL, Heller JG, Silcox DH, Hutton WC. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine (Phila Pa 1976). 1997;22(9):977982.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ito Z, Higashino K, Kato S, et al. Pedicle screws can be 4 times stronger than lateral mass screws for insertion in the midcervical spine: a biomechanical study on strength of fixation. J Spinal Disord Tech. 2014;27(2):8085.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Johnston TL, Karaikovic EE, Lautenschlager EP, Marcu D. Cervical pedicle screws vs. lateral mass screws: uniplanar fatigue analysis and residual pullout strengths. Spine J. 2006;6(6):667672.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Menon VK. Mechanically relevant anatomy of the axis vertebra and its relation to hangman’s fracture: an illustrated essay. Neurospine. 2019;16(2):223230.

  • 30

    Cho SK, Riew KD. Adjacent segment disease following cervical spine surgery. J Am Acad Orthop Surg. 2013;21(1):311.

  • 31

    Morishita Y, Naito M, Hymanson H, Miyazaki M, Wu G, Wang JC. The relationship between the cervical spinal canal diameter and the pathological changes in the cervical spine. Eur Spine J. 2009;18(6):877883.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Lee BS, Walsh KM, Lubelski D, et al. The effect of C2–3 disc angle on postoperative adverse events in cervical spondylotic myelopathy. J Neurosurg Spine. 2018;30(1):3845.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Shen J, McGraw M, Truong VT, et al. C2–C3 vertebral disc angle: An analysis of patients with and without cervical spondylotic myelopathy. Neurochirurgie. 2021;67(4):346349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Protopsaltis TS, Ramchandran S, Tishelman JC, et al. The importance of C2 slope, a singular marker of cervical deformity, correlates with patient-reported outcomes. Spine (Phila Pa 1976). 2020;45(3):184192.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Woodroffe RW, Helland L, Hollatz C, et al. Impact of the inclusion of C2 in posterior cervical fusions for cervical myelopathy on sagittal cervical alignment. Clin Spine Surg. 2020;33(4):E141E146.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Takeuchi K, Yokoyama T, Numasawa T, Itabashi T, Yamasaki Y, Kudo H. A novel posterior approach preserving three muscles inserted at C2 in multilevel cervical posterior decompression and fusion using C2 pedicle screws. Eur Spine J. 2018;27(6):13491357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Nguyen NL, Kong CY, Hart RA. Proximal junctional kyphosis and failure-diagnosis, prevention, and treatment. Curr Rev Musculoskelet Med. 2016;9(3):299308.

  • 38

    Hyun SJ, Lee BH, Park JH, Kim KJ, Jahng TA, Kim HJ. Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery. Korean J Spine. 2017;14(4):126132.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Kim HJ, Yang JH, Chang DG, et al. Proximal junctional kyphosis in adult spinal deformity: definition, classification, risk factors, and prevention strategies. Asian Spine J. 2022;16(3):440450.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Wilson JRF, Badhiwala JH, Moghaddamjou A, Yee A, Wilson JR, Fehlings MG. Frailty is a better predictor than age of mortality and perioperative complications after surgery for degenerative cervical myelopathy: an analysis of 41,369 patients from the NSQIP Database 2010. J Clin Med. 2020;9(11):3491.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Laverdière C, Georgiopoulos M, Ames CP, et al. Adult spinal deformity surgery and frailty: a systematic review. Global Spine J. 2022;12(4):689699.

  • 42

    Klepinowski T, Pala B, Cembik J, Sagan L. Prevalence of high-riding vertebral artery: a meta-analysis of the anatomical variant affecting choice of craniocervical fusion method and its outcome. World Neurosurg. 2020;143:e474e481.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Chen YR, Chan AY, Kumar KK, Veeravagu A. Cervical fracture/subluxation in a patient with a prior C2-sacrum fusion: case report and review of literature. Cureus. 2016;8(11):e888.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Li Y, Levi A. Proximal adjacent segment disease manifesting as retroodontoid pseudotumor after fusion to C2. World Neurosurg. 2020;133:9096.

  • 45

    Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. Accessed October 25, 2023. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

    • PubMed
    • Search Google Scholar
    • Export Citation

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