When can we expect global sagittal alignment to reach a stable value following cervical deformity surgery?

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  • 1 Department of Orthopedics, Hospital for Special Surgery, New York, New York;
  • | 2 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;
  • | 3 Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California;
  • | 4 Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York;
  • | 5 Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina;
  • | 6 Scripps Clinic, San Diego, California;
  • | 7 Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri;
  • | 8 Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California; and
  • | 9 Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado
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OBJECTIVE

Cervical deformity (CD) is a complex condition with a clear impact on patient quality of life, which can be improved with surgical treatment. Previous study following thoracolumbar surgery demonstrated a spontaneous and maintained improvement in cervical alignment following lumbar pedicle subtraction osteotomy (PSO). In this study the authors aimed to investigate the complementary questions of whether cervical alignment induces a change in global alignment and whether this change stabilizes over time.

METHODS

To analyze spontaneous changes, this study included only patients with at least 5 levels remaining unfused following surgery. After data were obtained for the entire cohort, repeated-measures analyses were conducted between preoperative baseline and 3-month and 1-year follow-ups with a post hoc analysis and Bonferroni correction. A subanalysis of patients with 2-year follow-up was performed.

RESULTS

One-year follow-up data were available for 121 of 168 patients (72%), and 89 patients had at least 5 levels remaining unfused following surgery. Preoperatively there was a moderate anterior cervical alignment (C2–7, −7.7° [kyphosis]; T1 slope minus cervical lordosis, 37.1°; cervical sagittal vertebral axis [cSVA], 37 mm) combined with a posterior global alignment (SVA, −8 mm) with lumbar hyperextension (pelvic incidence [PI] minus lumbar lordosis [LL] mismatch [PI-LL], −0.6°). Patients underwent a significant correction of the cervical alignment (median ΔC2–7, 13.6°). Simultaneously, PI-LL, T1 pelvic angle (TPA), and SVA increased significantly (all p < 0.05) between baseline and 3-month and 1-year follow-ups. Post hoc analysis demonstrated that all of the changes occurred between baseline and 3 months. Subanalysis of patients with complete 2-year follow-up demonstrated similar results, with stable postoperative thoracolumbar alignment achieved at 3 months.

CONCLUSIONS

Correction of cervical malalignment can have a significant impact on thoracolumbar regional and global alignment. Peak relaxation of compensatory mechanisms is achieved by the 3-month follow-up and tends to remain stable. Subanalysis with 2-year data further supports this finding. These findings can help to identify when the results of cervical surgery on global alignment can be best evaluated.

ABBREVIATIONS

ACD = adult CD; CD = cervical deformity; cSVA = cervical SVA; LIV = lowermost instrumented vertebra; LL = lumbar lordosis; PI = pelvic incidence; PI-LL = PI-LL mismatch, measured as PI minus LL; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SVA = sagittal vertebral axis; TK = thoracic kyphosis; TPA = T1 pelvic angle; TS-CL = thoracic slope minus cervical lordosis.

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