Do the newly proposed realignment targets for C2 and T1 slope bridge the gap between radiographic and clinical success in corrective surgery for adult cervical deformity?

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  • 1 Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York;
  • | 2 New York Spine Institute, New York, New York;
  • | 3 University of Oxford, United Kingdom;
  • | 4 Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany;
  • | 5 Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;
  • | 6 Department of Orthopedics, SUNY Downstate, Brooklyn, New York;
  • | 7 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas;
  • | 8 Department of Orthopedics, Hospital for Special Surgery, New York, New York; and
  • | 9 Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York
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OBJECTIVE

Surgical correction of cervical deformity (CD) has been associated with superior alignment and functional outcomes. It has not yet been determined whether baseline or postoperative T1 slope (T1S) and C2 slope (C2S) correlate with health-related quality-of-life (HRQoL) metrics and radiographic complications, such as distal junctional kyphosis (DJK) and distal junctional failure (DJF). The objective of this study was to determine the impact of T1S and C2S deformity severity on HRQoL metrics and DJF development in patients with CD who underwent a cervical fusion procedure.

METHODS

All operative CD patients with upper instrumented vertebra above C7 and preoperative (baseline) and up to 2-year postoperative radiographic and HRQoL data were included. CD was defined as meeting at least one of the following radiographic parameters: C2–7 lordosis < −15°, TS1–cervical lordosis mismatch > 35°, segmental cervical kyphosis > 15° across any 3 vertebrae between C2 and T1, C2–7 sagittal vertical axis > 4 cm, McGregor’s slope > 20°, or chin-brow vertical angle > 25°. Spearman’s rank-order correlation and linear regression analysis assessed the impact of T1S and C2S on HRQoL metrics (Neck Disability Index [NDI], modified Japanese Orthopaedic Association [mJOA] scale, EuroQOL 5-Dimension Questionnaire [EQ-5D] visual analog scale [VAS] score, and numeric rating scale [NRS]–neck) and complications (DJK, DJF, reoperation). Logistic regression and a conditional inference tree (CIT) were used to determine radiographic thresholds for achieving optimal clinical outcome, defined as meeting good clinical outcome criteria (≥ 2 of the following: NDI < 20 or meeting minimal clinically important difference, mild myelopathy [mJOA score ≥ 14], and NRS-neck ≤ 5 or improved by ≥ 2 points), not undergoing reoperation, or developing DJF or mechanical complication by 2 years.

RESULTS

One hundred five patients with CD met inclusion criteria. By surgical approach, 14.7% underwent an anterior-only approach, 46.1% a posterior-only approach, and 39.2% combined anterior and posterior approaches. The mean baseline radiographic parameters were T1S 28.3° ± 14.5° and C2S 25.9° ± 17.5°. Significant associations were found between 3-month C2S and mJOA score (r = −0.248, p = 0.034), NDI (r = 0.399, p = 0.001), EQ-5D VAS (r = −0.532, p < 0.001), NRS-neck (r = 0.239, p = 0.040), and NRS-back (r = 0.264, p = 0.021), while significant correlation was also found between 3-month T1S and mJOA score (r = −0.314, p = 0.026), NDI (r = 0.445, p = 0.001), EQ-5D VAS (r = −0.347, p = 0.018), and NRS-neck (r = 0.269, p = 0.049). A significant correlation was also found between development of DJF and 3-month C2S (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.01–1.1, p = 0.015) as well as for T1S (OR 1.1, 95% CI 1.01–1.1, p = 0.023). Logistic regression with CIT identified thresholds for optimal outcome by 2 years: optimal 3-month T1S < 26° (OR 5.6) and C2S < 10° (OR 10.4), severe 3-month T1S < 45.5° (OR 0.2) and C2S < 38.0° (no patient above this threshold achieved optimal outcome; all p < 0.05). Patients below both optimal thresholds achieved rates of 0% for DJK and DJF, and 100% met optimal outcome.

CONCLUSIONS

The severity of CD, defined by T1S and C2S at baseline and especially at 3 months, can be predictive of postoperative functional improvement and occurrence of worrisome complications in patients with CD, necessitating the use of thresholds in surgical planning to achieve optimal outcomes.

ABBREVIATIONS

C2S = C2 slope; CCI = Charlson Comorbidity Index; CD = cervical deformity; CI = confidence interval; CIT = conditional inference tree; CL = cervical lordosis; cSVA = cervical SVA; DJF = distal junctional failure; DJK = distal junctional kyphosis; EBL = estimated blood loss; EQ-5D = EuroQOL 5-Dimension Questionnaire; HRQoL = health-related quality of life; LIV = lowest instrumented vertebra; LL = lumbar lordosis; MCID = minimal clinically important difference; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; OR = odds ratio; PI = pelvic incidence; PT = pelvic tilt; SVA = sagittal vertical axis; T1S = T1 slope; TS-CL = TS1-CL mismatch; VAS = visual analog scale.

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