Proximal and distal reciprocal changes following cervical deformity malalignment correction

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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 Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York;
  • | 4 Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York;
  • | 5 Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California;
  • | 6 Scripps Clinic, San Diego, California;
  • | 7 Department of Orthopaedics, Washington University, St. Louis, Missouri;
  • | 8 Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina;
  • | 9 Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado; and
  • | 10 Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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OBJECTIVE

Hyperextension of C0–2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0–2 hyperextension and improved clinical outcomes.

METHODS

A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2–7 and C0–2. The association between C2–7 correction and change in C0–2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2–7 percentiles.

RESULTS

Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2–7, −11.7° ± 18.2°; T1 slope–cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] −12.8 ± 71.2 mm), and hyperlordosis at C0–2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2–7 and C0–2, respectively, with an ROE of approximately 9° for each segment. Limited C0–2 ROM and ROE correlated with the Neck Disability Index (r = −0.371 and −0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2–7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0–2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to −49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0–2 ROM increased to 27.6° ± 8.1° and C2–7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2–7 lordosis significantly correlated with increased TK (r = −0.617, p < 0.001), decreased C0–2 (r = −0.747, p < 0.001), and increased C0–2 ROE (r = 0.550, p = 0.002).

CONCLUSIONS

CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0–2 ROE and TK and was also associated with improved clinical outcome.

ABBREVIATIONS

BMP = bone morphogenetic protein; CCI = Charlson Comorbidity Index; CD = cervical deformity; CL = cervical lordosis; cSVA = cervical SVA; EBL = estimated blood loss; HRQOL = health-related quality of life; IQR = interquartile range; LIV = lowermost instrumented vertebra; LL = lumbar lordosis; LOS = length of stay; MGS = McGregor’s slope; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PI = pelvic incidence; PI-LL = PI-LL mismatch; PT = pelvic tilt; ROE = reserve of extension; ROM = range of motion; SVA = sagittal vertical axis; T1S = T1 slope; TK = thoracic kyphosis; TLK = thoracolumbar kyphosis; TPA = T1 pelvic angle; TS-CL = T1S-CL mismatch; UIV = uppermost instrumented vertebra.

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