Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy

Presented at the 2012 Joint Spine Section Meeting 

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Object

Sagittal spinopelvic malalignment is a significant cause of pain and disability in patients with adult spinal deformity. Surgical correction of spinopelvic malalignment can result in compensatory changes in spinal alignment outside of the fused spinal segments. These compensatory changes, termed reciprocal changes, have been defined for thoracic and lumbar regions but not for the cervical spine. The object of this study was to evaluate postoperative reciprocal changes within the cervical spine following lumbar pedicle subtraction osteotomy (PSO).

Methods

This was a multicenter retrospective radiographic analysis of patients from International Spine Study Group centers. Inclusion criteria were as follows: adults (>18 years old) with spinal deformity treated using lumbar PSO, a preoperative C7–S1 plumb line greater than 5 cm, and availability of pre- and postoperative full-length standing radiographs.

Results

Seventy-five patients (60 women, mean age 59 years) were included. The lumbar PSO significantly improved sagittal alignment, including the C7–S1 plumb line, C7–T12 inclination, and pelvic tilt (p <0.001). After lumbar PSO, reciprocal changes were seen to occur in C2–7 cervical lordosis (from 30.8° to 21.6°, p <0.001), C2–7 plumb line (from 27.0 mm to 22.9 mm), and T-1 slope (from −38.9° to −30.4°, p <0.001). Ideal correction of sagittal malalignment (postoperative sagittal vertical alignment < 50 mm) was associated with the greatest relaxation of cervical hyperlordosis (−12.4° vs −5.7°, p = 0.037). A change in cervical lordosis correlated with changes in T-1 slope (r = −0.621, p <0.001), C7–T12 inclination (r = 0.418, p <0.001), T12–S1 angle (r = −0.339, p = 0.005), and C7–S1 plumb line (r = 0.289, p = 0.018). Radiographic parameters that correlated with changes in cervical lordosis on multivariate linear regression analysis included change in T-1 slope and change in C2–7 plumb line (r2 = 0.53, p <0.001).

Conclusions

Adults with positive sagittal spinopelvic malalignment compensate with abnormally increased cervical lordosis in an effort to maintain horizontal gaze. Surgical correction of sagittal malalignment results in improvement of the abnormal cervical hyperlordosis through reciprocal changes.

Abbreviations used in this paper:ASD = adult spinal deformity; ISSG = International Spine Study Group; LL = lumbar lordosis; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SS = sacral slope; SVA = sagittal vertical alignment; TK = thoracic kyphosis.

Article Information

Address correspondence to: Christopher P. Ames, M.D., Department of Neurosurgery, University of California, San Francisco, 400 Parnassus Avenue, A850, San Francisco, California 94143-0112. email: amesc@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online August 3, 2012; DOI: 10.3171/2012.6.SPINE1250.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case example. Preoperative (A and B) and postoperative (C and D) sagittal radiographs showing measurement markup. Note the decrease in cervical lordosis following lumbar PSO. CL = cervical lordosis; PL = plumb line.

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    Diagrammatic demonstration of the changes in sagittal spinopelvic alignment that occur after lumbar PSO. Left: Depiction of significant positive sagittal malalignment, increased cervical lordosis to maintain horizontal gaze, and a lumbar wedge symbolizing the bone removal for a lumbar PSO. Right: Depiction of corrected sagittal alignment and decrease of cervical lordosis following closure of a lumbar PSO. Printed with permission from Kenneth Xavier Probst.

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