Applicability of cervical sagittal vertical axis, cervical lordosis, and T1 slope on pain and disability outcomes after anterior cervical discectomy and fusion in patients without deformity

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Understanding what influences pain and disability following anterior cervical discectomy and fusion (ACDF) in patients with degenerative cervical spine disease is critical. This study examines the timing of clinical improvement and identifies factors (including spinal alignment) associated with worse outcomes.


Consecutive adult patients were enrolled in a prospective outcomes database from two academic centers participating in the Quality Outcomes Database from 2013 to 2016. Demographics, surgical details, radiographic data, arm and neck pain (visual analog scale [VAS] scores), and disability (Neck Disability Index [NDI] and EQ-5D scores) were reviewed. Multivariate analysis was used.


A total of 186 patients were included, and 48.4% were male. Their mean age was 55.4 years, and 45.7% had myelopathy. Preoperative cervical sagittal vertical axis (cSVA), cervical lordosis (CL), and T1 slope values were 24.9 mm (range 0–55 mm), 10.4° (range −6.0° to 44°), and 28.3° (range 14.0°–51.0°), respectively. ACDF was performed at 1, 2, and 3 levels in 47.8%, 42.0%, and 10.2% of patients, respectively. Preoperative neck and arm VAS scores were 5.7 and 5.4, respectively. NDI and EQ-5D scores were 22.1 and 0.5, respectively. There was significant improvement in all outcomes at 3 months (p < 0.001) and 12 months (p < 0.001). At 3 months, neck VAS (3.0), arm VAS (2.2), NDI (12.7), and EQ-5D (0.7) scores were improved, and at 12 months, neck VAS (2.8), arm VAS (2.3), NDI (11.7), and EQ-5D (0.8) score improvements were sustained. Improvements occurred within the first 3-month period; there was no significant difference in outcomes between the 3-month and 12-month mark. There was no correlation among cSVA, CL, or T1 slope with any outcome endpoint. The most consistent independent preoperative factors associated with worse outcomes were high neck and arm VAS scores and a severe NDI result (p < 0.001). Similar findings were seen with worse NDI and EQ-5D scores (p < 0.001). A significant linear trend of worse NDI and EQ-5D scores at 3 and 12 months was associated with worse baseline scores. Of the 186 patients, 171 (91.9%) had 3-month follow-up data, and 162 (87.1%) had 12-month follow-up data.


ACDF is effective in improving pain and disability, and improvement occurs within 3 months of surgery. cSVA, CL, and T1 slope do not appear to influence outcomes following ACDF surgery in the population with degenerative cervical disease. Therefore, in patients with relatively normal cervical parameters, augmenting alignment or lordosis is likely unnecessary. Worse preoperative pain and disability were independently associated with worse outcomes.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; CL = cervical lordosis; cSVA = cervical SVA; HRQOL = health-related quality of life; NDI = Neck Disability Index; QOD = Quality Outcomes Database; SVA = sagittal vertical axis; VAS = visual analog scale.

Supplementary Materials

  • Supplemental Tables 1 and 2 (PDF 441 KB)
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Contributor Notes

Correspondence Darryl Lau: University of California, San Francisco, CA. WHEN CITING Published online October 18, 2019; DOI: 10.3171/2019.7.SPINE19437.Disclosures Dr. Chan receives support of non–study-related clinical or research efforts that he oversees from Orthofix. Dr. Chou reports that he is a consultant for Medtronic and Globus; he receives royalties from Globus. Dr. Bisson reports she is a consultant for nView and MiRus; she owns stock in MiRus. Dr. Mummaneni reports he is a consultant for DePuy Spine, Stryker, and Globus; he owns stock in Spinicity-ISD; he receives support of non–study-related efforts that he oversees from NREF and ISSG; he receives royalties from DePuy Spine, Thieme, and Springer; and he receives honoria from Spineart.


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