Prospective multi-centric evaluation of upper cervical and infra-cervical sagittal compensatory alignment in patients with adult cervical deformity

International Spine Study Group

Research output: Contribution to journalArticle

Abstract

Purpose: Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively. Methods: Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2–C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°–10°, CK-high > 10°] and cSVA (cSVA-low 0–4 cm, cSVA-mid 4–6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment. Results: 75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0–C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0–C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0–C2 (39°–35°, p = 0.01) which positively correlated with magnitude of deformity correction. Conclusions: Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.

Original languageEnglish (US)
Pages (from-to)1-10
Number of pages10
JournalEuropean Spine Journal
DOIs
StateAccepted/In press - Nov 28 2017

Fingerprint

Kyphosis
Lordosis
Chin
Scoliosis
Maintenance
Databases

Keywords

  • Alignment
  • Cervical deformity
  • Compensation
  • Horizontal gaze
  • Upper cervical lordosis

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

Prospective multi-centric evaluation of upper cervical and infra-cervical sagittal compensatory alignment in patients with adult cervical deformity. / International Spine Study Group.

In: European Spine Journal, 28.11.2017, p. 1-10.

Research output: Contribution to journalArticle

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title = "Prospective multi-centric evaluation of upper cervical and infra-cervical sagittal compensatory alignment in patients with adult cervical deformity",
abstract = "Purpose: Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively. Methods: Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2–C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°–10°, CK-high > 10°] and cSVA (cSVA-low 0–4 cm, cSVA-mid 4–6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment. Results: 75 CD patients (mean age 61.3 years, 56{\%} women) were included. Patients with progressively larger CK had a progressive increase in C0–C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0–C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0–C2 (39°–35°, p = 0.01) which positively correlated with magnitude of deformity correction. Conclusions: Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.",
keywords = "Alignment, Cervical deformity, Compensation, Horizontal gaze, Upper cervical lordosis",
author = "{International Spine Study Group} and Subaraman Ramchandran and Protopsaltis, {Themistocles S.} and Daniel Sciubba and Scheer, {Justin K.} and Jalai, {Cyrus M.} and Alan Daniels and Passias, {Peter G.} and Virginie Lafage and Kim, {Han Jo} and Gregory Mundis and Eric Klineberg and Hart, {Robert A.} and Smith, {Justin S.} and Christopher Shaffrey and Ames, {Christopher P.}",
year = "2017",
month = "11",
day = "28",
doi = "10.1007/s00586-017-5395-x",
language = "English (US)",
pages = "1--10",
journal = "European Spine Journal",
issn = "0940-6719",
publisher = "Springer Verlag",

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T1 - Prospective multi-centric evaluation of upper cervical and infra-cervical sagittal compensatory alignment in patients with adult cervical deformity

AU - International Spine Study Group

AU - Ramchandran, Subaraman

AU - Protopsaltis, Themistocles S.

AU - Sciubba, Daniel

AU - Scheer, Justin K.

AU - Jalai, Cyrus M.

AU - Daniels, Alan

AU - Passias, Peter G.

AU - Lafage, Virginie

AU - Kim, Han Jo

AU - Mundis, Gregory

AU - Klineberg, Eric

AU - Hart, Robert A.

AU - Smith, Justin S.

AU - Shaffrey, Christopher

AU - Ames, Christopher P.

PY - 2017/11/28

Y1 - 2017/11/28

N2 - Purpose: Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively. Methods: Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2–C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°–10°, CK-high > 10°] and cSVA (cSVA-low 0–4 cm, cSVA-mid 4–6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment. Results: 75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0–C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0–C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0–C2 (39°–35°, p = 0.01) which positively correlated with magnitude of deformity correction. Conclusions: Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.

AB - Purpose: Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively. Methods: Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2–C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°–10°, CK-high > 10°] and cSVA (cSVA-low 0–4 cm, cSVA-mid 4–6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment. Results: 75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0–C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0–C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0–C2 (39°–35°, p = 0.01) which positively correlated with magnitude of deformity correction. Conclusions: Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.

KW - Alignment

KW - Cervical deformity

KW - Compensation

KW - Horizontal gaze

KW - Upper cervical lordosis

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