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Analysis of Successful Versus Failed Radiographic Outcomes After Cervical Deformity Surgery

Protopsaltis, Themistocles S. MD; Ramchandran, Subaraman MD; Hamilton, D. Kojo MD; Sciubba, Daniel MD; Passias, Peter G. MD; Lafage, Virginie PhD§; Lafage, Renaud MS§; Smith, Justin S. MD PhD; Hart, Robert A. MD||; Gupta, Munish MD∗∗; Burton, Douglas MD††; Bess, Shay MD§§; Shaffrey, Christopher MD; Ames, Christopher P. MD‡‡; International Spine Study Group (ISSG)

doi: 10.1097/BRS.0000000000002524

Study Design. Prospective multicenter cohort study with consecutive enrollment.

Objective. To evaluate preoperative alignment and surgical factors associated with suboptimal early postoperative radiographic outcomes after surgery for cervical deformity.

Summary of Background Data. Recent studies have demonstrated correlation between cervical sagittal alignment and patient-reported outcomes. Few studies have explored cervical deformity correction prospectively, and the factors that result in successful versus failed cervical alignment corrections remain unclear.

Methods. Patients with adult cervical deformity (ACD) included with either cervical kyphosis more than 10°, C2-C7 sagittal vertical axis (cSVA) of more than 4 cm, or chin-brow vertical angle of more than 25°. Patients were categorized into failed outcomes group if cSVA of more than 4 cm or T1 slope and cervical lordosis (TS-CL) of more than 20° at 6 months postoperatively.

Results. A total of 71 patients with ACD (mean age 62 yr, 56% women, 41% revisions) were included. Fourty-five had primary cervical deformities and 26 at the cervico-thoracic junction. Thirty-three (46.4%) had failed radiographic outcomes by cSVA and 46 (64.7%) by TS-CL. Failure to restore cSVA was associated with worse preoperative C2 pelvic tilt angle (CPT: 64.4° vs. 47.8°, P = 0.01), worse postoperative C2 slope (35.0° vs. 23.8°, P = 0.004), TS-CL (35.2° vs. 24.9°, P = 0.01), CPT (47.9° vs. 28.2°, P < 0.001), “+” Schwab modifiers (P = 0.007), revision surgery (P = 0.05), and failure to address the secondary, thoracolumbar driver of the deformity (P = 0.02). Failure to correct TS-CL was associated with worse preoperative cervical kyphosis (10.4° vs. –2.1°, P = 0.03), CPT (52.6° vs. 39.1°, P = 0.04), worse postoperative C2 slope (30.2° vs. 13.3°, P < 0.001), cervical lordosis (–3.6° vs. –15.1°, P = 0.01), and CPT (37.7° vs. 24.0°, P < 0.001). Multivariate analysis revealed postoperative distal junctional kyphosis associated with suboptimal outcomes by cSVA (odds ratio 0.06, confidence interval 0.01–0.4, P = 0.004) and TS-CL (odds ratio 0.15, confidence interval 0.02–0.97, P = 0.05).

Conclusion. Factors associated with failure to correct the cSVA included revision surgery, worse preoperative CPT, and concurrent thoracolumbar deformity. Failure to correct the TS-CL mismatch was associated with worse preoperative cervical kyphosis and CPT. Occurrence of early postoperative distal junctional kyphosis significantly affects postoperative radiographic outcomes.

Level of Evidence: 3

Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, New York, NY

Department of Neurosurgery, University of Pittsburg Medical Center, Pittsburgh, PA

Department of Orthopedic Surgery, Johns Hopkins University Medical Center, Baltimore MD

§Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY

Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA

||Swedish Neuroscience Institute, Seattle, WA

∗∗Department of Orthopedic Surgery, Washington University Medical Center, St. Louis, MO

††Department of Orthopedic Surgery, Kansas University Hospital, Kansas City, KS

‡‡Department of Neurosurgery, University of California San Francisco, San Francisco, CA

§§Department of Orthopaedic Surgery, Denver International Spine Clinic, Denver, CO.

Address correspondence and reprint requests to Themistocles S. Protopsaltis, MD, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, 306 East 15th St, New York, NY 10003; E-mail:

Received 17 May, 2017

Revised 10 October, 2017

Accepted 16 November, 2017

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, grants, payment for lecture, stocks.

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