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The Relationship Between Improvements in Myelopathy and Sagittal Realignment in Cervical Deformity Surgery Outcomes

Passias, Peter Gust, MD; Horn, Samantha R., BA; Bortz, Cole A., BA; Ramachandran, Subaraman, MD; Burton, Douglas C., MD; Protopsaltis, Themistocles, MD; Lafage, Renaud, MS; Lafage, Virginie, PhD; Diebo, Bassel G., MD§; Poorman, Gregory W., BA; Segreto, Frank A., BS; Smith, Justin S., MD; Ames, Christopher, MD||; Shaffrey, Christopher I., MD; Kim, Han Jo, MD; Neuman, Brian, MD∗∗; Daniels, Alan H., MD; Soroceanu, Alexandra, MD††; Klineberg, Eric, MD‡‡; International Spine Study Group (ISSG)§§

doi: 10.1097/BRS.0000000000002610

Study Design. Retrospective review.

Objective. Determine whether alignment or myelopathy improvement drives patient outcomes after cervical deformity (CD) corrective surgery.

Summary of Background Data. CD correction involves radiographic malalignment correction and procedures to improve motor function and pain. It is unknown whether alignment or myelopathy improvement drives patient outcomes.

Methods. Inclusion: Patients with CD with baseline/1-year radiographic and outcome scores. Cervical alignment improvement was defined by improvement in Ames CD modifiers. modified Japanese Orthopaedic Association (mJOA) improvement was defined as mild [15–17], moderate [12–14], severe [<12]. Patient groups included those who only improved in alignment, those who only improved in mJOA, those who improved in both, and those who did not improve. Changes in quality-of-life scores (neck disability index [NDI], EuroQuol-5 dimensions [EQ-5D], mJOA) were evaluated between groups.

Results. A total of 70 patients (62 yr, 51% F) were included. Overall preoperative mJOA score was 13.04 ± 2.35. At baseline, 21 (30%) patients had mild myelopathy, 33 (47%) moderate, and 16 (23%) severe. Out of 70 patients 30 (44%) improved in mJOA and 13 (18.6%) met 1-year mJOA minimal clinically important difference. Distribution of improvement groups: 16/70 (23%) alignment-only improvement, 13 (19%) myelopathy-only improvement, 18 (26%) alignment and myelopathy improvement, and 23 (33%) no improvement. EQ-5D improved in 11 of 16 (69%) alignment-only patients, 11 of 18 (61%) myelopathy/alignment improvement, 13 of 13 (100%) myelopathy-only, and 10 of 23 (44%) no myelopathy/alignment improvement. There were no differences in decompression, baseline alignment, mJOA, EQ-5D, or NDI between groups. Patients who improved only in myelopathy showed significant differences in baseline-1Y EQ-5D (baseline: 0.74, 1 yr:0.83, P < 0.001). One-year C2-S1 sagittal vertical axis (SVA; mJOA r = −0.424, P = 0.002; EQ-5D r = −0.261, P = 0.050; NDI r = 0.321, P = 0.015) and C7-S1 SVA (mJOA r = −0.494, P < 0.001; EQ-5D r = −0.284, P = 0.031; NDI r = 0.334, P = 0.010) were correlated with improvement in health-related qualities of life.

Conclusion. After CD-corrective surgery, improvements in myelopathy symptoms and functional score were associated with superior 1-year patient-reported outcomes. Although there were no relationships between cervical-specific sagittal parameters and patient outcomes, global parameters of C2-S1 SVA and C7-S1 SVA showed significant correlations with overall 1-year mJOA, EQ-5D, and NDI. These results highlight myelopathy improvement as a key driver of patient-reported outcomes, and confirm the importance of sagittal alignment in patients with CD.

Level of Evidence: 3

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY

Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS

Department of Orthopedics, Hospital for Special Surgery, New York, NY

§Department of Orthopedics, SUNY Downstate Medical Center, Brooklyn, NY

Department of Neurosurgery, University of Virginia, Charlottesville, VA

||Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA

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

††Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada

‡‡Department of Orthopedic Surgery, University of California, Davis, Davis, CA

§§Denver, CO.

Address correspondence and reprint requests to Peter Gust Passias, MD, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital – NYU School of Medicine – NY Spine Institute – 301 East 17th St, New York, NY, 10003; E-mail:

Received 25 August, 2017

Revised 15 November, 2017

Accepted 5 January, 2018

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

The International Spine Study Group (ISSG) is funded through research grants from DePuy Spine and individual donations.

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

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