The association between cervical spine curvature and neck pain

Muscular endurance and its association with neck pain, disability, neck awareness, and kinesiophobia in patients with chronic neck pain

BACKGROUND

Recent studies revealed the connection between the endurance of neck muscles and pain, neck awareness, and fear of movement in patients with chronic neck pain in literature.

OBJECTIVES

To investigate the association between cervical, scapular, trunk, and upper extremity muscles' endurance and neck pain, disability, neck awareness, and kinesiophobia in patients with chronic neck pain.

DESIGN

Cross-sectional, observational study.

METHODS

Thirty-six patients with chronic neck pain (aged 18-65 years) were included in the study. Endurance tests were performed for 9 muscles/muscle groups in the cervical and scapular region, upper limb, and trunk. Pain severity, neck disability, neck awareness, and fear of movement were measured by Visual Analog Scale (VAS), Neck Disability Index (NDI), Fremantle Neck Awareness Questionnaire (FreNAQ), and Tampa Scale of Kinesiophobia (TSK), respectively.

RESULTS

Negative, weak-to-moderate relations were found between VAS (at rest and during activity) and the endurance of muscles evaluated in the cervical and scapular regions, upper extremity, and trunk as well as between NDI and endurance of the same muscles, similar to the relations between FreNAQ scores and the endurance of the cervical flexor, anterior trunk flexor, and upper extremity muscles (p < 0.05). No relation was found between the endurance of the muscles and TSK (p > 0.05).

CONCLUSIONS

Since the decrease in upper extremity, scapular region, and trunk muscles' endurance may contribute to neck pain and disability, and decrease neck awareness in patients with chronic neck pain; the evaluation of muscular endurance of upper body and trunk should also be considered.

CLINICAL TRIALS

NCT05121467.

Cervical kyphosis after posterior cervical laminectomy with and without fusion

BACKGROUND

Cervical posterior instrumentation and fusion is often performed to avoid post-laminectomy kyphosis. However, larger comparative analyses of cervical laminectomy with or without fusion are sparse.

METHODS

A retrospective, two-center, comparative cohort study included patients after stand-alone dorsal laminectomy with (n = 91) or without (n = 46) additional fusion for degenerative cervical myelopathy with a median follow-up of 59 (interquartile range (IQR) 52) months. The primary outcome was the C2-7 Cobb angle and secondary outcomes were Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scale, revision rates, T1 slope and C2-7 sagittal vertical axis (C2-7 SVA) at final follow-up. Logistic regression analysis adjusted for potential confounders (i.e. age, operated levels, and follow-up).

RESULTS

Preoperative C2-7 Cobb angle and T1 slope were higher in the laminectomy group, while the C2-7 SVA was similar. The decrease in C2-7 Cobb angle from pre- to postoperatively was more pronounced in the laminectomy group (- 6° (IQR 20) versus -1° (IQR 7), p = 0.002). When adjusting for confounders, the decrease in C2-7 Cobb angle remained higher in the laminectomy group (coefficient - 12 (95% confidence interval (CI) -18 to -5), p = 0.001). However, there were no adjusted differences for postoperative NDI (- 11 (- 23 to 2), p = 0.10), mJOA, revision rates, T1 slope and C2-7 SVA.

CONCLUSION

Posterior cervical laminectomy without fusion is associated with mild loss of cervical lordosis of around 6° in the mid-term after approximately five years, however without any clinical relevance regarding NDI or mJOA in well-selected patients (particularly in shorter segment laminectomies of < 3 levels).

The Effectiveness of Exercise Programs in Adolescents with Thoracic Kyphosis: A Narrative Review

Thoracic kyphosis is a common postural problem affecting over 20% of adolescents. This condition can contribute to various spinal problems, leading to a decreased ability to perform daily activities, reduced quality of life, and impaired pulmonary function. This review aimed to investigate the effectiveness of exercise programs in adolescents with thoracic kyphosis. We systematically searched the PubMed, Embase, Cochrane Library, and Scopus databases for articles relevant to adolescents with thoracic kyphosis that had been published up to 14 May 2024. Our inclusion criteria focused on studies investigating the effects of exercise on improving thoracic kyphosis. A total of 1883 articles was identified using the search terms. After the titles and abstracts had been screened, 1868 articles were found not to meet our inclusion criteria and were excluded. The remaining 15 articles were then assessed for eligibility. Finally, only seven studies were included in this systematic review. Exercises targeting the entire spinal curvature demonstrated efficacy in enhancing the strength and function of the cervical, thoracic, lumbar, and pelvic muscles, resulting in a corrective effect on thoracic kyphosis in adolescents. Consequently, exercise programs have emerged as potentially beneficial treatment approaches to improve poor posture and reduce adolescent thoracic kyphosis.

A New Index for Cervical Curvature Evaluation - Relative Cervical Curvature Area

OBJECTIVE

To put forward a new index of cervical curvature evaluation - relative cervical curvature area, and a new classification of cervical spine was proposed according to the relative cervical curvature area.

METHODS

A total of 167 subjects with cervical spondylosis were included in the study. Firstly, 119 subjects were selected to measure C2-C7 lordosis angle by Cobb angle method, Harrison posterior tangent method, and Jackson physiological stress line method, and then their relative cervical curvature area, C1-C7 Cobb angle, C7 slope, and T1 slope were measured. The correlation between relative cervical curvature area and 3 measurement methods and common sagittal parameters was analyzed. According to the angle classification method, we calculated the diagnostic boundary value of the relative cervical curvature area classification, and selected 48 subjects to evaluate its diagnostic efficacy. Finally, 119 subjects were re-evaluated according to the diagnostic threshold and the number of intersections to verify the feasibility of the new classification.

RESULTS

The results showed that the relative cervical curvature area index had good intraobserver and interobserver repeatability. Relative cervical curvature area was correlated with Harrison posterior tangent method (r = 0.930), Cobb angle method (r = 0.886), and Jackson physiological stress line method (r = 0.920), and correlated with C1-C7 Cobb angle, C7 slope, and T1 slope. The relative cervical curvature area has a good diagnostic performance for distinguishing patients with lordosis, straightening, and kyphosis. According to the new classification of cervical spine, 119 subjects were divided into 57 simple lordosis, 11 simple straightening, 4 simple kyphosis, 26 S-type, and 21 RS-type.

CONCLUSIONS

The relative cervical curvature area uses the area parameter instead of the original angle parameter and distance parameter to incorporate the change of segmental curvature, which makes up for the shortcomings of the Cobb angle method that only evaluates the curvature of 2 vertebrae, and better reflects the cervical curvature. Studies have shown that relative cervical curvature area has good repeatability and diagnostic value, and found that it has a good correlation with common cervical sagittal parameters. The new classification of cervical spine makes up for the disadvantage that the angle classification method cannot distinguish between S-type and RS-type, and initially proposes to use the number of intersections and the relative absolute value area to reflect the severity of S-type.

An investigation into the chiropractic practice and communication of routine repetitive radiographic imaging for the location of postural misalignments

Many clinicians use radiological imaging in efforts to locate and diagnose the cause of their patient's pain, relying on X-rays as a leading tool in clinical evaluation. This is fundamentally flawed because an X-ray represents a "snapshot" of the structural appearance of the spine and gives no indication of the current function of the spine. The health and well-being of any system, including the spinal motion segments, depend on the inter-relationship between structure and function. Pain, tissue damage, and injury are not always directly correlated. Due to such a high incidence of abnormalities found in asymptomatic patients, the diagnostic validity of X-rays can be questioned, especially when used in isolation of history and/or proper clinical assessment. The utility of routine X-rays is, therefore, questionable. One may posit that their application promotes overdiagnosis, and unvalidated treatment of X-ray findings (such as changes in postural curvature), which may mislead patients into believing these changes are directly responsible for their pain. A substantial amount of research has shown that there is no association between pain and reversed cervical curves. Accuracy can also be questioned, as X-ray measurements can vary based on the patient's standing position, which research shows is influenced by an overwhelming number of factors, such as patient positioning, patient physical and morphological changes over time, doctor interreliability, stress, pain, the patient's previous night's sleep or physical activity, hydration, and/or emotional state. Furthermore, research has concluded that strong evidence links various potential harms with routine, repeated X-rays, such as altered treatment procedures, overdiagnosis, radiation exposure, and unnecessary costs. Over the past two decades, medical boards and health associations worldwide have made a substantial effort to communicate better "when" imaging is required, with most education around reducing radiographic imaging. In this review, we describe concerns relating to the high-frequency, routine use of spinal X-rays in the primary care setting for spine-related pain in the absence of red-flag clinical signs.

Capturing the cervical spine shape: Angular measurements versus geometric morphometric methods

The cervical spine manifests a wide shape variation. However, the traditional methods to evaluate the cervical spine curve were never tested against its actual shape. The study's main aim was to determine whether the shape classification of the cervical spine, based on traditional angular measurements, coincides with each other and with the shape captured by the 2D landmark-based geometric morphometric method. The study's second aim was to reveal the associations between the cervical spine shape and the demographic parameters, the head's position, and the spine's sagittal balance. CT scans of the cervical spine of 163 individuals were evaluated to achieve these goals. The shape was assessed by measuring the C2-C7 Cobb angle (CA), the C2-C7 posterior tangent angle (PTA), the curvedness of the arch, and by a 2D landmark-based geometric morphometric method. The position of the head and the sagittal balance of the spine were evaluated by measuring the foramen magnum-C2 Cobb angle (FMCA) and the T1 slope angle (T1SA), respectively. Based on the size of the angle measured, each individual was classified into one of the three cervical 'shape groups' (lordotic, straight, and kyphotic). We found that cervical lordosis was the dominant shape regardless of the measuring methods utilized (46.6%-54.6%), followed by straight neck (28.2%-30.1%), and kyphosis (15.3%-25.2%); however, about a third of the 163 individuals were classified into a different shape group using the CA and PTA methods. The cervical spine angle was sex-independent and age-dependent. The T1SA was significantly correlated with CA and PTA (r = 0.640 and r = 0.585, respectively; p < 0.001). In conclusion, the cervical spine shape evaluation is method-dependent and varies with age.

Relationship between cervical lordotic angle and cervical segmental motion during craniocervical flexion test: A cross-sectional study

The craniocervical flexion test (CCFT) is commonly used for assessing the performance and function of the deep cervical flexor muscles; however, objective measurements of cervical segmental motion during craniocervical flexion (CCF) are lacking. Therefore, the purpose of this study aimed to investigate cervical segmental motions during CCFT and determine the relationship between changes of cervical segmental motions and the cervical lordotic angle. A cross-sectional study of prospectively collected data. Twenty healthy participants without neck pain underwent standing cervical radiography (lateral view) to measure the cervical lordotic angle, followed by radiography in supine position during the CCFT. The occipito-atlantal (OA) joint angle, atlantoaxial (AA) joint angle, and cervical spinous process posterior displacement (CSPPD) of the C1-C6 vertebrae were measured using lateral cervical radiographs taken during the initial (20 mm Hg) and low-stage (24 mm Hg) CCFT conditions. The CCF motion during the low-stage CCFT was characterized by a significantly increased OA joint angle, decreased AA joint angle, and increased C1-C6 CSPPD compared with the initial stage (P < .05). The change in the value of C1-C6 CSPPD at low-stage CCFT showed a significant positive correlation with the cervical lordotic angle. These results indicate that the cervical lordotic angle is important in minimizing CSPPD and performing appropriately-isolated CCF motion during CCFT.

Comparison of Cervical Sagittal Parameters among Patients with Neck Pain and Patients with Cervical Spondylotic Radiculopathy and Cervical Spondylotic Myelopathy

OBJECTIVE

Previous studies have shown that cervical sagittal alignment is strongly associated with cervical deformity, myelopathy, and cervical adjacent-segmental disease, and these cervical sagittal parameters are correlated with health-related quality of life. However, less attention has been paid to cervical sagittal balance in various cervical disorders. This study aimed to compare cervical sagittal parameters between patients with nonspecific neck pain (NS-NP) and patients with cervical spondylotic radiculopathy (CSR) and cervical spondylotic myelopathy (CSM).

METHODS

We retrospectively examined 236 patients from between January 2020 and October 2022. We divided them into three groups (NS-NP, CSR, and CSM) and collected general information and cervical sagittal parameters for these patients. The variation of parameters between the size of these parameters and gender differences was analyzed. Pearson's or Spearman's correlation was applied to analyze the association of cervical sagittal parameters of all patients between the three groups.

RESULTS

There were significant differences in age and sex among the three groups (p < 0.001), with the NS-NP group being the youngest and NS-NP being more common in women. The parameters of cervical sagittal position significantly differed among the three groups (p < 0.05). Pearson's or Spearman's correlation result showed that the C2-C7 Cobb angle was negatively associated with the C2-C7 sagittal vertical angle (SVA), and the C2-C7 Cobb angle and T1 slope (T1s) were negatively associated with the spino-cranial angle (SCA). There was a positive correlation between the C2-C7 Cobb angle and C7 slope (C7s), C2-C7 SVA and T1s, C2-C7 SVA and SCA, and C7s and T1s.

CONCLUSION

This study showed that between the three groups, patients with nonspecific neck pain had smaller SCA, and among patients with NS-NP, women had more significant SCA. The smaller anteroposterior diameter of the thorax in women might explain this difference.

Analysis of Clinical Pattern of Musculoskeletal Disorders in the Cervical and Cervico-Thoracic Regions of the Spine

Background: Cervical spine disorders (CSDs) are a common cause of neck pain. Proper diagnosis is of great importance in planning the management of a patient with neck pain. Hence, the aim of this study is to provide an overview of the clinical pattern of early-stage functional disorders affecting the cervical and cervico-thoracic regions of the spine, considering the age and sex of the subjects. Methods: Two hundred adult volunteers were included in the study. Manual examination of segments C0/C1-Th3/Th4 was performed according to the methodology of the Katenborn-Evjenth manual therapy concept and the spine curvatures were assessed (cervical lordosis and thoracic kyphosis). Results: The most common restricted movement was lateral flexion to the left, and the least disturbed movement were observed in the sagittal plane (flexion and extension). The most affected segment was C7/Th1 (71.5% participants had problems in this segment), and the least affected segment was Th3/Th4 (69.5% participants had no mobility disorders in this segment). The number of disturbed segments did not differ between men and women (p > 0.05), but increased with age (r = 0.14, p = 0.04). Conclusions: Cervical mobility in adult population is frequently restricted. The number of affected segments increased with age and was not sex-dependent.

The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score

STUDY DESIGN/SETTING

Retrospective single-center study.

BACKGROUND

The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD).

PURPOSE

Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD.

METHODS

Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years.

RESULTS

One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF.

CONCLUSION

The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.

Prevalence and risk factors of occupational neck pain in Chinese male fighter pilots: a cross-sectional study based on questionnaire and cervical sagittal alignment

Background

Neck pain (NP) is a common musculoskeletal disorder among fighter pilots and has become a rising concern due to its detrimental impact on military combat effectiveness. The occurrence of NP is influenced by a variety of factors, but less attention has been paid to the association of NP with demographic, occupational, and cervical sagittal characteristics in this group. This study aimed to investigate the prevalence and risk factors of NP in Chinese male fighter pilots using a questionnaire and cervical sagittal measurements.

Methods

Demographic and flight-related data, as well as musculoskeletal pain information, were gathered from Chinese male fighter pilots via a self-report questionnaire. Cervical sagittal parameters were measured and subtypes were classified using standardized lateral cervical radiographs. Differences in various factors between the case and control groups were analyzed using t-tests or chi-square tests. Binary logistic regressions were conducted to explore potential risk factors contributing to NP. Predictors were presented as crude odds ratios (CORs) and adjusted odds ratios (AORs), along with their respective 95% confidence intervals (CIs).

Results

A total of 185 male fighter pilots were included in this cross-sectional study. Among them, 96 (51.9%) reported experiencing NP within the previous 12 months. The multivariate regression analysis revealed that continuous flight training (AOR: 4.695, 95% CI: 2.226-9.901, p < 0.001), shoulder pain (AOR: 11.891, 95% CI: 4.671-30.268, p < 0.001), and low back pain (AOR: 3.452, 95% CI: 1.600-7.446, p = 0.002) were significantly associated with NP.

Conclusion

The high 12-month prevalence of NP among Chinese male fighter pilots confirms the existence of this growing problem. Continuous flight training, shoulder pain, and low back pain have significant negative effects on pilots' neck health. Effective strategies are necessary to establish appropriate training schedules to reduce NP, and a more holistic perspective on musculoskeletal protection is needed. Given that spinal integrated balance and compensatory mechanisms may maintain individuals in a subclinical state, predicting the incidence of NP in fighter pilots based solely on sagittal characteristics in the cervical region may be inadequate.

Analysis of abnormal muscle activities in patients with loss of cervical lordosis: a cross-sectional study

BACKGROUND

This study aimed to detect the differences in cervical muscle activation patterns in people with versus without cervical lordosis and explore the possible mechanism of cervical pain originating therein.

METHODS

This cross-sectional design included 39 participants without and 18 with normal cervical lordosis. Muscular activation was measured for 5 s in both groups using surface electromyography. Subsequently, the root mean square (RMS) of muscle amplitude was obtained at the bilateral splenius capitis, upper and lower parts of the splenius cervicis, upper and lower parts of the semispinalis cervicis, sternocleidomastoid, upper trapezius, and rhomboid muscles in five cervical positions: 0° (resting), 30° of flexion, 30° of extension, 60° of extension, and upon a 1-kg load on the head in a resting posture.

RESULTS

The RMS values of the upper trapezius muscle at all postures and the rhomboid muscles at 60° of extension were significantly lower in the loss of lordosis than control group. Comparing the RMS ratio of each posture to the resting position, the ratio of the upper trapezius at flexion was significantly higher and that of the rhomboids at 60° of extension and upon loading was significantly lower in the loss of lordosis than control group. Moreover, the pattern changes in the RMS values according to posture showed a similar shape in these two muscles, and lower in the loss of lordosis than the normal group.

CONCLUSIONS

The loss of normal cervical alignment may correlate with predisposed conditions such as reduced muscle activation of the trapezius and rhomboid muscle, and may also provoke over-firing of the upper trapezius muscle, possibly increasing neck musculoskeletal pain.

TRIAL REGISTRATION

CLINICALTRIALS

gov, registration number: NCT03710785.

Prolonged slumped sitting causes neck pain and increased axioscapular muscle activity during a computer task in healthy participants - A randomized crossover study

INTRODUCTION

Sitting posture may contribute to spinal pain. Effects of postures on pain, sensitivity and muscle activity during computer tasks were investigated.

METHODS

Twenty-five healthy participants, seated at a workstation without backrest, completed four, 15-min typing tasks: A)Upright with forearm-support; B)Upright without forearm-support; C)Slumped with forearm-support; D)Slumped without forearm-support. Participants rated pain every minute on a numerical rating scale (NRS). RMS-EMG was recorded from upper/lower trapezius (UT, LT), serratus anterior and anterior/middle deltoid. At baseline and after tasks, pressure pain thresholds (PPTs) were recorded bilaterally over the head, UT, and leg.

RESULTS

All tasks caused clinically relevant increased NRS (≥2/10) compared to baseline (P < 0.001). NRS was higher in Task-D (P < 0.003) and lower in Task-B (P < 0.005) than others. PPTs did not change from baseline. Task-D caused higher UT and LT RMS-EMG (P < 0.02) than other tasks.

CONCLUSION

A 15-min task caused pain irrespective of posture with some causing larger changes than others.

Expressed Beliefs about the Cause of Pain in a Pediatric Population: A Qualitative Study

(1) Background: The aims of this study are to explore what beliefs children and adolescents manifest about the cause of the pain they describe, to compare whether there are differences between beliefs by age and the persistence of pain, and to relate the explanations of the cause of pain with current scientific evidence. (2) Methods: a cross-sectional qualitative study was used. The primary endpoint of the study was obtaining explanations of the cause of pain recorded by means of an open-ended question. The participants were school-age children attending a charted school in the province of Barcelona. (3) Results: The children and adolescents proposed a diverse range of explanations for the cause of pain that they reported in their responses. The most frequent explanation for the cause of pain were pathologies and injuries (45.95%), ergonomic issues (22.60%) and psychological issues (15.95%). (4) Conclusions: There is a lot of variety in the explanations that young people give about the cause of their pain in schoolchildren aged between 10 and 16 years old. There exists a high prevalence of explanations non-associated with tissue damage (ENAD) concerning the causes of pain described. It is necessary that future health prevention programs dedicated to early ages consider which beliefs about the cause of pain are the most frequent in the pediatric population.

Acute Progressive Pediatric Post-Traumatic Kyphotic Deformity

Cervical kyphosis is a rare entity with challenging management due to the limitations of pediatric age, along with a growing spine. The pathogenesis is made up of a large group of congenital, syndromic and acquired deformities after posterior element deterioration or as a result of previous trauma or surgery. In rare progressive cases, kyphotic deformities may result in severe "chin-on-chest" deformities with severe limitations. The pathogenesis of progression to severe kyphotic deformity after minor hyperflexion trauma is not clear without an obvious MR pathology; it is most likely multifactorial. The authors present the case of a six-month progression of a pediatric cervical kyphotic deformity caused by a cervical spine hyperflexion injury, and an MR evaluation without the pathology of disc or major ligaments. Surgical therapy with a posterior fixation and fusion, together with the preservation of the anterior growing zones of the cervical spine, are potentially beneficial strategies to achieve an excellent curve correction and an optimal long-term clinical outcome in this age group.

Predicting surgical outcome and sagittal alignment change in patients with cervical spondylosis and degenerative kyphosis after anterior cervical discectomy and fusion

The aim of this study was to forecast the risk factors of poor outcomes and postoperative loss of lordosis or recurrence of kyphosis. In this retrospective study, 101 patients with cervical spondylosis and preoperative kyphosis who underwent anterior cervical discectomy and fusion (ACDF) were enrolled, between June 2015 and June 2019. Patients were grouped according to the recovery rate of Japanese Orthopaedic Association (JOA) score whether more than 50%, and the change of postoperative cervical Cobb angle. There were 22 cases with less than 50% of recovery rate and 35 cases with the worsening of postoperative sagittal alignment (WPSA). Multivariate linear-regression analysis was conducted with the data. Advanced age (p = 0.019), longer duration of symptoms (p = 0.003) and loss of local Cobb angle (LCA) after surgery (p = 0.031) was significantly associated with a poor clinical outcome. A whole kyphosis (p = 0.009), aggravated neck pain after surgery (p = 0.012), preoperative lower thoracic 1 (T1) (p < 0.001), bigger change of C2-7 sagittal vertical axis (SVA) (p = 0.008) and adjacent segment degeneration (ASD) (p = 0.024) was significantly associated with the WPSA. Preoperative health education, nutritional support and early postoperative rehabilitation intervention, in perioperative period, were recommended for patients with advance age, longer duration of symptoms, whole cervical kyphosis and lower T1. Postoperative sagittal malalignment was related to neck pain and ASD after surgery.

Effects of Combined Exercise Program on Spinal Curvature and Balance Ability in Adolescents with Kyphosis

Thoracic hyperkyphosis is associated with postural abnormality, physical function, and quality of life. This study aimed to examine the effects of a combined exercise program on the spinal curvature and balance ability in adolescents with kyphosis. Fifty-one adolescents (mean age 21.95 ± 3.90 year, 23 male and 28 female) diagnosed with kyphosis were randomly divided into two groups: an experimental group (n = 25) and a control group (n = 26). All participants in the study group underwent a combined exercise program for 60 min, three times per week, for 12 weeks. Cobb’s angle and forward head angle showed significant differences between the two groups (p < 0.001). The anterior and posterior weight distributions of static and dynamic plantar foot pressures showed a significant difference between the two groups (p < 0.001), and significant differences were observed only in the study group (p < 0.001). However, the left and right static plantar foot pressures did not differ significantly. In conclusion, these results demonstrate that a combined exercise program is an effective intervention for the improvement of alignment in the spinal curve and balance in adolescents with postural kyphosis.

Prevalence of text neck posture, smartphone addiction, and its association with neck disorders among university students in the Kingdom of Saudi Arabia during the COVID-19 pandemic

The smartphone emerges as an inevitable gadget in modern society and its increased usage results in neck disorders among its users. However, the factors associated with neck disorders among smartphone users are ambiguous and less explored in the literature. The purpose of this research was to determine the prevalence of text neck posture, smartphone addiction/overuse, and its association with neck disorders among university students in the Kingdom of Saudi Arabia during the COVID-19 pandemic. A total of 313 university students who were aged 18 years and older, owned a smartphone, and used it during the preceding 12 months participated in this cross-sectional study. A self-administered questionnaire was used to collect data regarding the prevalence of text neck posture, smartphone addiction/overuse, neck disorders, and the level of physical activity. Binary logistic regression was used to determine the association between the prevalence of neck disorders and text neck posture, smartphone addiction/overuse, and level of physical activity. The 12 months prevalence of neck disorders due to smartphone use among the participants was found to be 46%. The neck disorders were more prevalent among participants who reported text neck posture (P < 0.001) and categorized as smartphone-addicted/overuse (P < 0.001). Measures to promote the awareness of healthy use of smartphones including postural education and to decrease its screen time are warranted to reduce neck disorders.

The Effect of Subsidence on Segmental and Global Lordosis at Long-term Follow-up After Anterior Cervical Discectomy and Fusion

OBJECTIVE

Subsidence following anterior cervical discectomy and fusion (ACDF) may lead to disruptions of cervical alignment and lordosis. The purpose of this study was to evaluate the effect of subsidence on segmental, regional, and global lordosis.

METHODS

This was a retrospective cohort study performed between 2016-2021 at a single institution. All measurements were performed using lateral cervical radiographs at the immediate postoperative period and at final follow-up greater than 6 months after surgery. Associations between subsidence and segmental lordosis, total fused lordosis, C2-7 lordosis, and cervical sagittal vertical alignment change were determined using Pearson correlation and multivariate logistic regression analyses.

RESULTS

One hundred thirty-one patients and 244 levels were included in the study. There were 41 one-level fusions, 67 two-level fusions, and 23 three-level fusions. The median follow-up time was 366 days (interquartile range, 239-566 days). Segmental subsidence was significantly negatively associated with segmental lordosis change in the Pearson (r = -0.154, p = 0.016) and multivariate analyses (beta = -3.78; 95% confidence interval, -7.15 to -0.42; p = 0.028) but no associations between segmental or total fused subsidence and any other measures of cervical alignment were observed.

CONCLUSION

We found that subsidence is associated with segmental lordosis loss 6 months following ACDF. Surgeons should minimize subsidence to prevent long-term clinical symptoms associated with poor cervical alignment.

The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up

Sagittal cervical alignment is a clinically related feature in patients suffering from chronic cervical spondylotic radiculopathy (CSR). We designed this randomized trial to explore the effects of cervical lordosis (CL) correction in thirty chronic lower CSR patients with CL < 20°. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received neck stretching and exercises and infrared radiation; additionally, the SG received cervical extension traction. Treatments were applied 3× per week for 10 weeks after which groups were followed for 3 months and 2 years. The amplitude of dermatomal somatosensory evoked potentials (DSSEPS), CL C2−C7, and pain scales (NRS) were measured. The SG had an increase in CL post-treatment (p < 0.0001), this was maintained at 3 months and 2 years. No statistical improvement in CL was found for the CG. A significant reduction in NRS for SG after 10 weeks of treatment with non-significant loss of change at 3 months and continued improvement at 2 years was found. CG had less significant improvement in post-treatment NRS; the 3-month and 2-year measures revealed significant worsening in NRS. An inverse linear correlation between increased CL and NRS was found (r = −0.49; p = 0.005) for both groups initially and maintained in SG at the final 2-year follow-up (r = −0.6; p = 0.01). At 10 weeks, we found significant improvements in DSSEPS for both groups (p < 0.0001). We identified a linear correlation between initial DSSEPs and CL for both groups (p < 0.0001), maintained only in the SG at the final follow-up for all levels (p < 0.0001). Improved CL in the SG correlated with significant improvements in nerve root function and pain rating in patients with CSR at short and long-term follow-up. These observed effects indicate that clinicians involved in the treatment of patients with symptoms of cervical degenerative disorders should add sagittal curve correction to their armamentarium of rehabilitation procedures for relevant patient populations.

The cervical sagittal curvature change in patients with or without PCSM after laminoplasty

Objective

After laminoplasty, the cervical sagittal curvature of some patients tend to be lordotic, this phenomenon cannot be explained by the theory of laminoplasty, and the reason remains unknown. We explored the possible role played by pinching cervical spondylotic myelopathy (PCSM) in the cervical sagittal curvature change in patients after laminoplasty.

Methods

From April 2017 to May 2019, we studied 122 patients undergoing laminoplasty with cervical spondylotic myelopathy (CSM). All patients were divided into Group A (anterior compression only, without PCSM) and Group B (both anterior and posterior compression, with PCSM). The visual analogue scale (VAS) was used to measure pain, and modified Japanese Orthopedic Association (mJOA) score was derived. The cervical global angle (CGA) and the range of cervical motion (ROM) were compared. The clinical and imaging results were compared between Group A and Group B.

Results

After laminoplasty, both the mean VAS and mJOA scores improved significantly in Group A and Group B, the mJOA recovery rate of Group B was better than that of Group A (P < 0.05). The mean CGA and ROM decreased in Group A, but increased in Group B. MRI revealed that the ligamentum flavum of Group A was significantly thinner than that of Group B (P < 0.05).

Conclusions

Because of the hypertrophic and folded ligamentum flavum compressing the dorsal spinal cord, patients with PCSM may maintain a compulsive kyphotic posture. After laminoplasty, the cervical sagittal curvature of these patients tend to be lordotic due to the release of dorsal spinal cord compression.

Effect of a Posture-Cueing Shirt on Sitting Posture During a Functional Task in Healthy Participants: A Randomized Cross-Over Study

OBJECTIVES

The purpose of this study was to investigate the effect of a posture-cueing shirt on sitting posture during a functional task.

METHODS

Thirty healthy male participants were seated at a standardized workstation while completing 3 laptop writing tasks of 15-minute duration wearing either a posture-cueing shirt, a compression shirt, or no shirt. Posture was assessed based on photos taken at minutes 1 and 15 into the writing task from which the head and shoulder angles were measured and extracted for analysis. After each task, participants rated any potential pain they felt during the task on an 11-point numeric rating scale (NRS).

RESULTS

The results showed that none of the shirts significantly affected the head or shoulder angles at any time point. Participants reported lower pain levels after using the posture-cueing shirt (NRS 0 [0-1]) compared with no shirt (NRS 1 [0-2]; P = .012). No significant difference in pain levels was observed between shirts.

CONCLUSION

Although posture did not change in any conditions for these healthy male subjects, the posture-cueing shirt resulted in a lower pain intensity compared with no shirt but not with a compression shirt. Although a significant difference was found for pain intensity favoring the posture-cueing shirt, this difference was negligible, and thus its value to reduce pain or improve posture in healthy subjects remains in question.

Sagittal imbalance of the spine is associated with poor sitting posture among primary and secondary school students in China: a cross-sectional study

Background

Long-term poor posture may affect the morphological development of the spine. However, there is no definite answer as to how writing posture affects students’ spine. This study attempted to compare the sagittal curvature of the spine between sitting and standing postures in adolescents to reveal the variation rule of spinal sagittal curvature of students with learning posture, and to discover the key factors that may affect students’ spinal health.

Methods

1138 participants (male, 604; female, 534; age range, 6–18 years) from three schools in Tianjin, China, including 570 primary school students and 568 secondary school students. This study used SpineScan and PA200 Station Posture Assessment System to assess the sagittal curvature of the spine for three postures: sitting on a chair in upright position, seated at a desk while reading/writing, and standing in natural relaxed position. Analyze the difference between spine angle of the three postures and the correlation between the sagittal plane angle of the spine and body posture.

Results

The mean sagittal angle of the spine changed when the participants were in reading/writing position compared to standing position, with the lumbar lordosis angle significantly decreased (p < 0.05) and the thoracic kyphosis angle significantly increased (p < 0.05). The TKA and LLA angles were abnormal in 33 and 52% of students in reading/writing posture respectively. There was a significant correlation between sitting posture and standing spinal Angle and were positively correlated with the height of the teenager (p < 0.05). By contrast, a higher percentage of TKA and LLA subjects in the standard reading/writing posture reference range maintained normal spinal shape while standing.

Conclusions

The angle of thoracic kyphosis significantly increased from standing posture to upright sitting, reading/writing posture, while lumbar lordosis significantly decreased or even disappeared. There was a significant correlation between sagittal angle of spine in different postures. The poor sitting posture associated with sagittal angle abnormalities impact the shape of the spine such that sagittal imbalance was also observed when students in natural standing posture. Height is an important factor affecting the sitting spine shape of students.

A 540° posterior-anterior-posterior approach for 360° fused rigid severe cervical kyphosis: patient series

BACKGROUND

Treatment of severe rigid 360° fused cervical kyphosis (CK) is challenging and often requires a combined approach for ankylosis release, establishment of sagittal balance, and fixation with fusion.

OBSERVATIONS

Four patients with iatrogenic 360° fused severe rigid CK (Cobb angle ≥40°) were enrolled for this retrospective analysis. All patients in the case series were female, with an average age of 27 years. All patients previously underwent posterior laminectomy/laminoplasty and cervical tumor resection when they were children (13–17 years). They underwent correction surgery with a 540° posterior-anterior-posterior approach. Preoperative and final follow-up radiography and computed tomography (CT) were used to evaluate kyphosis correction, internal fixation implants, and bone fusion. The preoperative and final follow-up average C2–7 Cobb angles were −32.4° ± 12.0° and 5.3° ± 7.1°, respectively. Preoperative and final follow-up CK angles averaged −47.2° ± 7.4° and −0.9° ± 16.1°, respectively. The mean correction angle was 46.3° ± 9.6°. At final follow-up, CT showed stable fixation and solid bone fusion.

LESSONS

The rare iatrogenic severe kyphosis with 360° ankylosis requires a combined approach. The 540° posterior-anterior-posterior approach can completely release the bony fusion, and the CK can be corrected using an anterior plate. This technique can achieve good results and is an effective strategy.

Effects of a combination of scapular stabilization and thoracic extension exercises for office workers with forward head posture on the craniovertebral angle, respiration, pain, and disability: A randomized-controlled trial

Objectives

This study aims to investigate how exercise programs not directly applied to the cervical spine affect office workers with forward head posture (FHP).

Patients and methods

Between March 2018 and June 2018, a total of 32 office workers with FHP (13 males, 19 females; mean age 36.63 years; range, 23 to 57 years) were randomized either to experimental (n=16) or control groups (n=16). Scapular stabilization and thoracic extension exercises were applied to the experimental group and cervical stabilization and stretching exercises to the control group. The results of the pre-intervention and after six weeks measurement of the craniovertebral angle (CVA), respiration, pain, and disability were compared and analyzed.

Results

For intra-group comparison, both groups showed significant differences (p<0.05) in CVA, forced expiratory volume at 1 sec (FEV1), Visual Analog Scale (VAS), and neck disability index at pre- and post-intervention, while only the experimental group showed a significant difference (p<0.05) in maximum inspiratory pressure, maximum expiratory pressure, and forced vital capacity. For inter-group comparison, a significant difference (p<0.05) between FEV1 and VAS was observed.

Conclusion

The combination of scapular stabilization and thoracic extension exercises, not directly applied to the cervical spine, has an effect on improving the posture, respiration, neck pain, and disability in office workers with FHP.

Prioritization of realignment associated with superior clinical outcomes for surgical cervical deformity patients

Background:

To optimize quality of life in patients with cervical deformity (CD), there may be alignment targets to be prioritized.

Objective:

To prioritize the cervical parameter targets for alignment.

Methods:

Included: CD patients (C2–C7 Cobb >10^°°, C2–C7 lordosis [CL] >10^°°, cSVA > 4 cm, or chin-brow vertical angle >25^°°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical (C) or cervicothoracic (CT) Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (<4 cm) and T1 slope minus CL (TS-CL) (<15^°°) were excluded. Patients assessed: Meeting Minimal Clinically Important Difference (MCID) for NDI (<−15 ΔNDI). Ratios of correction were found for regional parameters categorized by Primary Ames Driver (C or CT). Decision tree analysis assessed cut-offs for differences associated with meeting NDI MCID at 1Y.

Results:

Seventy-seven CD patients (62.1 years, 64%F, 28.8 kg/m²). 41.6% met MCID for NDI. A backward linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R²= 0.820 (P = 0.032) included TS-CL, cSVA, MGS, C2SS, C2-T3 angle, C2-T3 sagittal vertical axis (SVA), CL. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the two groups (P > 0.050). Decision tree analysis determined cut-offs for radiographic change, prioritizing in the following order: ≥42.5^° C2-T3 angle, >35.4^° CL, <−31.76^° C2 slope, <−11.57 mm cSVA, <−2.16^° MGS, >−30.8 mm C2-T3 SVA, and ≤−33.6^° TS-CL.

Conclusions:

Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.

Does Cervical Alignment Matter? The Effect of 2-level Anterior Cervical Discectomy and Fusion on Sagittal Alignment and Patient-reported Outcomes

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

This study aimed to determine the change in cervical sagittal balance following 2-level anterior cervical discectomy and fusion (ACDF) and whether the degree of change was associated with improvement in patient-reported outcomes (PROs).

SUMMARY OF BACKGROUND DATA

Sagittal balance in cervical spine surgery has been recognized as an important surgical goal. However, its influence on clinical outcomes following anterior decompressive procedures remains debatable.

MATERIALS AND METHODS

Patients who underwent primary 2-level ACDF for cervical spondylotic radiculopathy and/or myelopathy were identified from an institutional spine registry. Radiographic measurements were done preoperatively, postoperatively, and at minimum 24 months follow-up. Measurements comprised segmental lordosis (SL), C2-C7 cervical lordosis (CL), C2-C7 sagittal vertical axis, C7 slope (C7S), T1 slope (T1S) and C7 slope minus cervical lordosis (C7S-CL). Disk heights were measured preoperatively and postoperatively. PROs including the Neck Disability Index, Short Form-36, and Visual Analog Scale for neck pain and arm pain were collected preoperatively and at 24 months postoperatively.

RESULTS

In total, 90 patients were included. Mean follow-up was 58.6±22.9 months. Significant improvement in all PROs was achieved at 24 months (P<0.05). SL was -1.2±8.2 degrees preoperatively, increased to 5.2±5.9 degrees postoperatively (P<0.001), and decreased to 1.2±6.2 degrees at follow-up (P=0.005). CL was 8.5±12.5 degrees preoperatively, increased to 10.8±12.4 degrees postoperatively (P=0.018), and maintained at 10.9±11.2 degrees at follow-up (P=0.030). Sagittal vertical axis, C7S, T1S, and C7S-CL did not change significantly. Significant increases in disk heights were achieved postoperatively (P<0.001). Fusion rate was 98.9% at follow-up. PROs were not related to radiologic measurements. Maintaining or increasing CL or SL was not related to a greater degree of improvement in PROs.

CONCLUSIONS

Two-level ACDF restored segmental and global CL, but changes in cervical sagittal alignment did not correlate with the magnitude of improvement in PROs. Adequate decompression with solid fusion remains fundamental to achieving good clinical outcomes in patients with degenerative cervical disease.

Prioritization of Realignment Associated With Superior Clinical Outcomes for Cervical Deformity Patients

Objective

To prioritize the cervical parameter targets for alignment.

Methods

Included: cervical deformity (CD) patients (C2–7 Cobb angle > 10°, cervical lordosis > 10°, cervical sagittal vertical axis [cSVA] > 4 cm, or chin-brow vertical angle > 25°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical [C] or cervicothoracic [CT] Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (< 4 cm) and T1 slope minus cervical lordosis (TS–CL) (< 15°) were excluded. Patients assessed: meeting minimum clinically important differences (MCID) for NDI (< -15 ΔNDI). Ratios of correction were found for regional parameters categorized by primary Ames driver (C or CT). Decision tree analysis assessed cutoffs for differences associated with meeting NDI MCID at 1Y.

Results

Seventy-seven CD patients (mean age, 62.1 years; 64% female; body mass index, 28.8 kg/m²). Forty-one point six percent of patients met MCID for NDI. A backwards linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R² of 0.820 (p=0.032) included TS–CL, cSVA, McGregor’s slope (MGS), C2 sacral slope, C2–T3 angle, C2–T3 SVA, cervical lordosis. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the 2 groups (p>0.050). Decision tree analysis determined cutoffs for radiographic change, prioritizing in the following order: ≥ 42.5° C2–T3 angle, > 35.4° cervical lordosis, < -31.76° C2 slope, < -11.57-mm cSVA, < -2.16° MGS, > -30.8-mm C2–T3 SVA, and ≤ -33.6° TS–CL.

Conclusion

Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.

Association of Spinal Manipulative Therapy With Changes in Cervical Motion Segment Interactions in Patients With Neck Pain: An Observational Study With Matched Asymptomatic Controls

OBJECTIVE

The objectives of this study were to determine (1) if maximal intervertebral range of motion (IV-RoMmax) and laxity interactions exist in the cervical spine during flexion, (2) if there are differences in IV-RoMmax or laxity parameters between baseline and follow-up in both patients with neck pain and asymptomatic controls, and (3) if there is an effect on IV-RoMmax/laxity relationships in patients with neck pain after spinal manipulative therapy.

METHODS

Twenty-nine patients with subacute or chronic neck pain and 33 asymptomatic controls were imaged during flexion and extension, pre and post a course of cervical chiropractic manipulation (patient group only), using a standardized quantitative fluoroscopy acquisition protocol.

RESULTS

Significant correlations between IV-RoMs were found in both neck pain and neck pain-free populations at baseline and follow-up. Positive relationships were found between C2-C3 and C3-C4 and C4-C5 and C5-C6 IV-RoM in both populations. A negative correlation was found in the patient group at baseline between C1-C2 and C5-C6, but not at follow-up. Significant relationships were also found for segmental laxity, with a negative correlation found at C1-C2 and C5-C6 in the patient group only and at baseline only.

CONCLUSION

Distinct relationships were found between both intraregional IV-RoM and laxity, many of which were present in both groups at baseline and follow-up, suggestive of normal kinematic behaviors. Changes in correlations unique to the patient group may be indicative of a change in regional kinematics resulting from the manipulation intervention. Spinal manipulative therapy may have a therapeutic effect by influencing cervical kinematics at the regional level.

Redefining cervical spine deformity classification through novel cutoffs: An assessment of the relationship between radiographic parameters and functional neurological outcomes

Purpose:

The aim is to investigate the relationship between cervical parameters and the modified Japanese Orthopedic Association scale (mJOA).

Materials and Methods:

Surgical adult cervical deformity (CD) patients were included in this retrospective analysis. After determining data followed a parametric distribution through the Shapiro–Wilk Normality (P = 0.15, P > 0.05), Pearson correlations were run for radiographic parameters and mJOA. For significant correlations, logistic regressions were performed to determine a threshold of radiographic measures for which the correlation with mJOA scores was most significant. mJOA score of 14 and <12 reported cut-off values for moderate (M) and severe (S) disability. New modifiers were compared to an existing classification using Spearman's rho and logistic regression analyses to predict outcomes up to 2 years.

Results:

A total of 123 CD patients were included (60.5 years, 65%F, 29.1 kg/m²). For significant baseline factors from Pearson correlations, the following thresholds were predicted: MGS (M:-12 to-9° and 0°–19°, P = 0.020; S: >19° and <−12°, χ²= 4.291, P = 0.036), TS-CL (M: 26°to 45°, P = 0.201; S: >45°, χ²= 7.8, P = 0.005), CL (M:-21° to 3°, χ²= 8.947, P = 0.004; S: <−21°, χ²= 9.3, P = 0.009), C2-T3 (M: −35° to −25°, χ²= 5.485, P = 0.046; S: <−35°, χ²= 4.1, P = 0.041), C2 Slope (M: 33° to 49°, P = 0.122; S: >49°, χ²= 5.7, P = 0.008), and Frailty (Mild: 0.18–0.27, P = 0.129; Severe: >0.27, P = 0.002). Compared to existing Ames- International Spine Study Group classification, the novel thresholds demonstrated significant predictive value for reoperation and mortality up to 2 years.

Conclusions:

Collectively, these radiographic values can be utilized in refining existing classifications and developing collective understanding of severity and surgical targets in corrective surgery for adult CD.

Predictors of Superior Recovery Kinetics in Adult Cervical Deformity Correction: An Analysis Using a Novel Area Under the Curve Methodology

STUDY DESIGN

Retrospective review of a prospective database.

OBJECTIVE

The aim of this study was to identify demographic, surgical, and radiographic factors that predict superior recovery kinetics following cervical deformity (CD) corrective surgery.

SUMMARY OF BACKGROUND DATA

Analyses of CD corrective surgery use area under the curve (AUC) to assess health-related quality of life (HRQL) metrics throughout recovery.

METHODS

Outcome measures were baseline (BL) to 1-year (1Y) health-related quality of life (HRQL) (Neck Disability Index [NDI]). CD criteria were C2-7 Cobb angle >10°, coronal Cobb angle >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, TS-CL >10°, or chin-brow vertical angle >25°. AUC normalization divided BL and postoperative outcomes by BL. Normalized scores (y axis) were plotted against follow-up (x axis). AUC was calculated and divided by cumulative follow-up length to determine overall, time-adjusted recovery (Integrated Health State [IHS]). IHS NDI was stratified by quartile, uppermost 25% being "Superior" Recovery Kinetics (SRK) versus "Normal" Recovery Kinetics (NRK). BL demographic, clinical, and surgical information predicted SRK using generalized linear modeling.

RESULTS

Ninety-eight patients included (62 ± 10 years, 28 ± 6 kg/m2, 65% females, Charlson Comorbidity Index: 0.95), 6% smokers, 31% smoking history. Surgical approach was: combined (33%), posterior (49%), anterior (18%). Posterior levels fused: 8.7, anterior: 3.6, estimated blood loss: 915.9ccs, operative time: 495 minutes. Ames BL classification: cSVA (53.2% minor deformity, 46.8% moderate), TS-CL (9.8% minor, 4.3% moderate, 85.9% marked), horizontal gaze (27.4% minor, 46.6% moderate, 26% marked). Relative to BL NDI (Mean: 47), normalized NDI decreased at 3 months (0.9 ± 0.5, P = 0.260) and 1Y (0.78 ± 0.41, P < 0.001). NDI IHS correlated with age (P = 0.011), sex (P = 0.042), anterior approach (P = 0.042), posterior approach (P = 0.042). Greater BL pelvic tilt (PT) (SRK: 25.6°, NRK: 17°, P = 0.002), pelvic incidence-lumbar lordosis (PI-LL) (SRK: 8.4°, NRK: -2.8°, P = 0.009), and anterior approach (SRK: 34.8%, NRK: 13.3%; P = 0.020) correlated with SRK. 69.4% met MCID for NDI (<Δ-15) and 63.3% met substantial clinical benefit for NDI (<Δ-10); 100% of SRK met both MCID and substantial clinical benefit. The predictive model for SRK included (AUC = 88.1%): BL visual analog scale (VAS) EuroQol five-dimensional descriptive system (EQ5D) (odds rario [OR] 0.96, 95% confidence interval [CI]: 0.92-0.99), BL swallow sleep score (OR: 1.04, 95% CI: 1.01-1.06), BL PT (OR: 1.12, 95% CI: 1.03-1.22), BL modified Japanese Orthopedic Association scale (mJOA) (OR: 1.5, 95% CI: 1.07-2.16), BL T4-T12, BL T10-L2, BL T12-S1, and BL L1-S1.

CONCLUSION

Superior recovery kinetics following CD surgery was predicted with high accuracy using BL patient-reported (VAS EQ5D, swallow sleep, mJOA) and radiographic factors (PT, TK, T10-L2, T12-S1, L1-S1). Awareness of these factors can improve decision-making and reduce postoperative neck disability.Level of Evidence: 3.

Correlation of supine MRI and standing radiographs for cervical sagittal balance in myelopathy patients: a cross-sectional study

PURPOSE

Cervical sagittal alignment is correlated with myelopathy severity and used by spinal surgeons for surgical planification. Magnetic resonance imaging (MRI) is the gold standard for the evaluation of cervical myelopathy but may not be for the assessment of cervical sagittal balance compared to X-rays. The objective of this study was to assess the correlation of cervical alignment between supine MRI and standing radiographs in patients with cervical spondylotic myelopathy (CSM).

METHODS

Cobb, Jackson and Harrison methods were used to measure cervical sagittal alignment on supine MRI and standing radiographs of CSM adults. Cervical alignment was divided based on Cobb angle values on lordotic (> 4°), kyphotic (< - 4°) and rectitude (- 4° to 4°). Correlations between radiographic and MRI measurements were determined. Intra- and interobserver reliability were assessed and MRI and X-Ray-measured angles were compared.

RESULTS

One hundred and thirty patients with CSM were reviewed. Correlations of cervical lordosis measures between radiographs and MRI were strong using the Cobb (0.65) and Jackson (0.63) methods, and moderate using the Harrison (0.37) method. Mean cervical lordosis angle was significantly lower on supine MRI compared to standing radiographs for all methods (Cobb 11.6 Rx vs. 9.2 MRI, Jackson 14.6 vs. 11.6, Harrison 23.5 vs. 19.9). Eighteen patients (15.4%) without lordosis on supine MRI presented lordosis on standing radiographs.

CONCLUSION

A substantial proportion of patients has sagittal alignment discrepancies between supine MRI and standing radiographs. Therefore, standing radiographs of the cervical spine should always be included in surgical planning of CSM patients.

A Novel Scoring System for Ossification of Posterior Longitudinal Ligament of the Cervical Spine Based on Magnetic Resonance Imaging-CSFM Scoring System

OBJECTIVE

To establish a new scoring system to assess spinal cord compression of ossification of posterior longitudinal ligament (OPLL) of the cervical spine.

METHODS

Literature review and expert advice were used to determine variables of the novel CSFM scoring system. The CSFM score included 4 variables: curvature of spinal cord (C), increased signal intensity of spinal cord (S), cerebrospinal fluid imaging (F), and cross-section morphology of spinal cord (M). From June 2015 to June 2018, clinical and imaging data of 387 patients with cervical OPLL were retrospectively analyzed. The 4 variables were measured and recorded. Different scores were assigned based on analysis of the relationship between the variables and the Japanese Orthopaedic Association score. Two spine surgeons scored the patients according to the CSFM score and analyzed the internal consistency and reliability of the CSFM score.

RESULTS

The CSFM scoring system consisted of 4 variables, each of which was divided into 4 grades. Each variable was assigned a score of 0-3 according to different grades. The total possible score was 12, and the minimum score was 0. A higher score indicated more severe spinal cord compression.

CONCLUSIONS

The CSFM scoring system can effectively reflect the degree of spinal cord compression for cervical OPLL.

Visualization of Human Spine Biomechanics for Spinal Surgery

We propose a visualization application, designed for the exploration of human spine simulation data. Our goal is to support research in biomechanical spine simulation and advance efforts to implement simulation-backed analysis in surgical applications. Biomechanical simulation is a state-of-the-art technique for analyzing load distributions of spinal structures. Through the inclusion of patient-specific data, such simulations may facilitate personalized treatment and customized surgical interventions. Difficulties in spine modelling and simulation can be partly attributed to poor result representation, which may also be a hindrance when introducing such techniques into a clinical environment. Comparisons of measurements across multiple similar anatomical structures and the integration of temporal data make commonly available diagrams and charts insufficient for an intuitive and systematic display of results. Therefore, we facilitate methods such as multiple coordinated views, abstraction and focus and context to display simulation outcomes in a dedicated tool. By linking the result data with patient-specific anatomy, we make relevant parameters tangible for clinicians. Furthermore, we introduce new concepts to show the directions of impact force vectors, which were not accessible before. We integrated our toolset into a spine segmentation and simulation pipeline and evaluated our methods with both surgeons and biomechanical researchers. When comparing our methods against standard representations that are currently in use, we found increases in accuracy and speed in data exploration tasks. in a qualitative review, domain experts deemed the tool highly useful when dealing with simulation result data, which typically combines time-dependent patient movement and the resulting force distributions on spinal structures.

Effectiveness and Safety of Polydioxanone Thread Embedding Acupuncture Compared to Physical Therapy in the Treatment of Patients with Non-Specific Chronic Neck Pain: An Assessor-Blinded, Randomized, Controlled, Clinical Trial

Background

Thread embedding acupuncture (TEA) has recently been used as a conservative treatment method for non-specific chronic neck pain (CNP). The objective of this study was to evaluate the effectiveness and safety of TEA compared to physical therapy (PT) for treating patients with CNP.

Methods

A total of 128 patients diagnosed with CNP were randomly assigned to a TEA group and a PT group at a 1:1 ratio. The TEA group received four sessions of TEA, while the PT group received eight sessions of PT over 4 weeks. Outcomes were assessed using Neck Pain and Disability Scale (NPDS), clinically important difference (CID), cervical spinal angle, Beck Depression Inventory II (BDI-II), Beck Anxiety Inventory (BAI), Patient Global Impression of Change (PGIC), and EuroQol Five-Dimension (EQ-5D) at baseline and 5, 9, and 13 weeks.

Results

The TEA group showed significant improvement in NPDS compared to the PT group at 5, 9, and 13 weeks. Proportions of patients with decreased NPDS scores of more than 11.5 points (minimal CID) were significantly higher in the TEA group at 5, 9, and 13 weeks. There were significant differences between the two groups at 5, 9, and 13 weeks for BDI-II, and at 5 and 9 weeks for BAI. For EQ-5D, the TEA group showed significant improvement at 5, 9, and 13 weeks. There was no significant difference in cervical spinal angle between the two groups. For PGIC, better improvement was observed at 9 and 13 weeks in the TEA group. Adverse events associated with interventions were mostly temporary and mild.

Conclusion

For patients with CNP, TEA treatment was found to be more effective than PT treatment for improving their pain and dysfunction, quality of life, and psychological distress. Despite some post-treatment discomfort, TEA treatment can be considered as a useful treatment method for patients with CNP.

Trial Registration

This trial has been registered 5 April 2019 in Clinical Research Information Service of South Korea (CRIS- KCT0003720).

Relationship Between Degeneration or Sagittal Balance With Modic Changes in the Cervical Spine

Objective: This study evaluates the relationship between degenerative and Modic changes (MCs) in the cervical spine and compares the results with the cervical sagittal balance parameters.

Methods: We retrospectively reviewed 275 patients with neck pain who applied to our outpatient clinic and underwent cervical magnetic resonance imaging (MRI) and cervical anteroposterior (AP)/lateral (Lat) X-ray radiography between January 2016 and January 2018. The clinics, demographic information, and radiological findings of the patients were examined. Modic changes, disc degeneration, and facet degeneration (FD) were examined by cervical MRI, and T1 slope and Cobb angle were measured by cervical AP/Lat X-ray radiography. These results were compared to evaluate their relations with each other.

Results: No relationship between the presence or absence of degenerative changes (Modic changes, facet degeneration, and disc degeneration) and sagittal balance parameters (T1 slope and Cobb angle) was found. However, when each cervical segment was examined separately, facet degeneration at the C4-C5 level and Modic changes at the C3-C4, C4-C5, and C6-C7 levels were statistically significant with the Cobb angles, and the Modic changes at the C3-C4 level and disc degeneration at the C2-C3 level were found to be significant with T1 slope values.

Conclusions: Our findings indicate that MCs increased with decreased cervical curvature, increasing disc and facet degeneration, although the causal mechanisms are not clear.

Clinical and radiological outcomes of kinesiotaping in patients with chronic neck pain: A double-blinded, randomized, placebo-controlled study

Objectives

In this study, we aimed to evaluate the efficacy of kinesiotaping (KT) in patients with chronic non-specific neck pain (NSNP) in terms of pain, disability, cervical range of motion (ROM), and cervical lordosis.

Patients and methods

Between October 2013 and March 2014, a total of 50 patients (10 males, 40 females; mean age 35.1±9.9 years; range, 17 to 62 years) with chronic NSNP were randomized into the KT (n=25) or the sham KT intervention (n=25) groups. Both groups were additionally given a therapeutic exercise (TE) program. The Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores and ROM measurements were recorded at baseline, at the end of treatment, and at one month. Lateral cervical digital radiographs were analyzed by the Cobb, posterior tangent and effective lordosis methods at baseline and at one month after the treatment.

Results

There was a statistically significant decrease in the VAS scores compared to baseline in the KT group. The NDI scores significantly decreased in both groups. The patients in the KT group experienced a significant increase in all planes of cervical ROM after the treatment. Cervical radiographs revealed a significant increase in the Cobb and posterior tangent angles only in the KT group.

Conclusion

Our study results suggest that KT significantly improves VAS, NDI scores, ROM and cervical lordosis angles. The combination of TE and KT is useful in reducing pain and disability and improving ROM and cervical lordosis loss in patients with chronic NSNP.

The importance of preoperative T1 slope for determining proper postoperative C2-7 Cobb's angle in patients undergoing cervical reconstruction

BACKGROUND

This study aimed to explore the relationship among different cervical sagittal parameters in asymptomatic volunteers and the correlation between surgical efficacy and difference of presumed and actual postoperative C2-7 Cobbs's angle (C2-7COBB), which was calculated based on preoperative T1 slope (T1S) in patients undergoing cervical reconstruction.

METHODS

In total, 158 inpatients with cervical spondylosis and 274 asymptomatic volunteers were retrospectively reviewed. Cervical sagittal parameters, such as C2-7COBB, T1S, thoracic inlet angle (TIA), and neck tilt (NT), were compared. Then, the correlation among these parameters was analyzed in asymptomatic volunteers, and a regression equation between T1S and C2-7COBB was established and used to analyze the correlation among the Japanese Orthopaedic Association (JOA) score improvement, the sagittal parameters, and the difference between presumed and actual postoperative C2-7COBB in patients after cervical reconstruction.

RESULTS

The mean T1S, C2-7COBB, and TIA were significantly decreased in patients (P < 0.01). T1S and NT had a strong correlation with TIA (P < 0.01). T1S demonstrated a moderate correlation with C2-7COBB in asymptomatic volunteers (r = 0.569, P < 0.01). A regression equation had been established as C2-7COBB = 0.742 × T1S - 0.866. The mean C2-7COBB and JOA score improved significantly (P < 0.05) postoperatively. Moreover, the JOA improvement rate showed a significant negative correlation with the difference in the presumed and actual postoperative C2-7COBB (r = - 0.696, P < 0.01).

CONCLUSION

Our study successfully established a regression equation for calculating postsurgical C2-7COBB based on the correlation between T1S and C2-7COBB in asymptomatic volunteers. The regression equation could be used for guiding surgeons to accomplish an ideal postsurgical C2-7COBB for patients with cervical spondylosis.

Temporal Trends in Cervical Spine Curvature of South Korean Adults Assessed by Deep Learning System Segmentation, 2006-2018

IMPORTANCE

The loss of the physiologic cervical lordotic curve is a common degenerative disorder known to be associated with abnormal spinal alignment. However, the changing trends among sex and age groups has not yet been well established.

OBJECTIVE

To analyze the temporal trends in cervical curvature across sex and age groups using an automated deep learning system (DLS).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted using lateral cervical radiographs of 13 691 individuals from January 1, 2006, to December 31, 2018. The degree of anterior vertical curvature was approximated by a DLS approach and convexity measurement method. This population-based study used the Yonsei University College of Medicine Severance Hospital, Seoul, South Korea, cohort database to identify 13 691 consecutive adults (≥18 years of age) who underwent standing lateral radiography in inpatient and outpatient settings.

MAIN OUTCOMES AND MEASURES

The prevalence of kyphotic and straight cervical curve as well as the trends of degree of cervical curvature in 2006 to 2018 among sex and age groups were determined. The DLS performance was validated with quantitative metrics and compared with interobserver and intraobserver variations.

RESULTS

Automatic cervical spine segmentation was identified from lateral radiographs of 13 691 individuals (mean [SD] age, 49.9 [15.3] years; 8051 women [58.8%]). From 2006 to 2018, the decrease in the lordotic curve was significant across both sexes and age groups younger than 70 years, with the decrease more pronounced in women and successively younger generations (female, -0.05; 95% CI, -0.06 to -0.04; 18-29 years of age, -0.06; 95% CI, -0.08 to -0.04; 30-39 years of age, -0.06; 95% CI, -0.08 to -0.04; and 40-49 years of age, -0.05; 95% CI, -0.06 to -0.03; all P < .001). The prevalence of straight and kyphotic curvature had a significant increasing trend for both sexes and young generations, in which individuals 18 to 29 years of age generally had the highest prevalence rates during the study cycle (in 2018, kyphosis, 16.7%; 95% CI, 10.8%-22.5%; straight, 45.5%; 95% CI, 37.7%-53.3%). Similar trends were observed with longitudinal analysis of repeated measures of individuals, with more pronounced decreases in lordotic curvature observed among women and young adults.

CONCLUSIONS AND RELEVANCE

This study suggests a significant, increasing loss of normal cervical lordotic curvature for both sexes and young adults that is greater in progressively younger cohorts and women. Further research is necessary to evaluate associations between neck pain and loss of cervical curvature and address the need for active promotion and practical interventions aimed at neck posture correction.

A new concept of motion preservation surgery of the cervical spine: PEEK rods for the posterior cervical region

BACKGROUND

Laminectomy may cause kyphotic postoperative deformity in the cervical region leading to segmental instability over time. Laminoplasty may be an alternative procedure to laminectomy, as it protects the spine against post-laminectomy kyphosis; however, similar to laminectomy, laminoplasty may cause sagittal plane deformities by destructing or weakening the dorsal tension band.

OBJECTIVE

Using finite element analysis (FE), we attempted to determine whether a posterior motion preservation system (PEEK posterior rod system concept) could overcome the postoperative complications of laminectomy and laminoplasty and eliminate the side effects of rigid posterior stabilization in the cervical region.

METHODS

We compared PEEK rods in four different diameters with a titanium rod for posterior cervical fixation. The present study may lead to motion preservation systems of the cervical vertebra.

RESULTS

When PEEK rod is compared with titanium rod, considerable increase in range of motion is observed.

CONCLUSIONS

PEEK rod-lateral mass screw instrumentation systems may be useful in motion preservation surgery of the posterior cervical region.

Correlation Between Parameters of Intervertebral Disc and Cervical Lordosis in Cervical Spondylotic Myelopathy

Background

In cervical disc degeneration, cervical disc height (CDH) and cervical disc angle (CDA)have a certain but unidentified relationship with cervical lordosis (CL). This study aimed to reveal the relationship among CDH, CDA, and CL in patients diagnosed with cervical spondylotic myelopathy (CSM).

Material/Methods

A retrospective analysis was conducted using the data of 212 CSM patients (136 males and 76 females). According to CL angle, patients were classified into 2 groups: patients with CL ≤10° constituted Group 1 (n=102); patients with CL >10° constituted Group 2 (n=110). The CDH, CDA, and CL were measured using X-ray imaging. Pearson correlation analysis measured the correlation between CDH, CDA, and CL. Multiple linear regression was utilized to analyze the effects of CDH and CDA on CL.

Results

The CDAs in every level were higher in Group 2 than those in Group 1 (P<0.05).CDH and CDA gradually increased with the increase in vertebral level and dropped at C5–C6 level in both groups. We found statistically significant correlations between C3/4H, C4/5H, C3/4A,C4/5A, C5/6A, and C6/7Aand CL in Group 1 (P<0.05), and between C4/5H, C3/4A, and C4/5Aand CL in Group 2 (P<0.05). C3/4A and C4/5A predicted CL in Group 1 (adjusted R²=0.176, P<0.001), while C4/5A predicted CL with high sensitivity in Group 2 (adjusted R²=0.198, P<0.001).

Conclusions

CDA contributes more than CDH to CL in CSM. Further studies are necessary to reveal the relationship between CL and cervical disc degeneration.

Is it Suitable to Fix the Occipito-C2 Angle and the Posterior Occipitocervical Angle in a Normal Range During Occipitocervical Fusion?

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

The objective of this study was (1) to measure the occipito-C2 angle (OC2A) and the posterior occipitocervical angle (POCA) in a normal population, and (2) to observe the effects of OC2A and POCA selection on postoperative clinical efficacy and lower cervical curvature after occipitocervical fusion (OCF) in patients with basilar invagination (BI) and atlantoaxial fracture and dislocation (AAFD).

SUMMARY OF BACKGROUND DATA

OC2A has received special attention with respect to the clinical efficacy during OCF. However, none of studies have focused on the relationship between OC2A and POCA and have assessed their impact on clinical outcomes in patients with different occipiocervical diseases.

MATERIALS AND METHODS

One hundred fifty healthy subjects without any cervical disease (healthy group) were randomly selected based on sex and age. Three spine surgeons measured the OC2A and POCA in the healthy group and averaged the values. Forty-two patients with BI (BI group) and 32 patients with AAFD (AAFD group) who underwent OCF between January 2012 and January 2017 were reviewed. OC2A, POCA, and cervical spinal angle (CSA) were measured preoperatively, postoperatively immediately after surgery and ambulation, and at the final follow-up visit. The preoperative and final follow-up visual analog scale (VAS), Japanese Orthopaedic Association score (JOA), neck disability index (NDI), and the change of CSA from postoperatively immediately after surgery and ambulation to the final follow-up (dCSA) were recorded.

RESULTS

The values of OC2A and POCA were 14.5±3.7 and 108.2±8.1 degrees in the healthy group, respectively, and the respective 95% confidence intervals were 7.2-21.8 and 92.3-124.0 degrees as the normal range. There was a negative correlation between OC2A and POCA (r=-0.386, P<0.001). The preoperative value of OC2A (5.6±4.3 degrees) in BI group was smaller than that in the healthy group (P<0.05); however, the preoperative value of POCA (123.0±10.4 degrees) in the BI group was larger than that in the healthy group (P<0.05). There was no significantly different of OC2A and POCA between the healthy group and the AAFD group before the operation (P>0.05). The preoperative value of CSA (25.7±9.5 degrees) in the BI group was larger than that in the AAFD group (16.5±5.1 degrees) (P<0.05). In the BI group, 26 patients had ideal OC2A and POCA (both within 95% confidence interval of the healthy group) postoperatively immediately after surgery and ambulation as a subgroup of the ideal angle group. In the remaining patients with BI (nonideal angle group), VAS, JOA, and NDI at the final follow-up were significantly better than those in the ideal angle group (P<0.05). The ideal angle group showed statistically greater dCSA than the nonideal angle group of the BI group (P<0.05). On the contrary, in the AAFD group, the NDI in the ideal angle group (20 patients) was better than that in the nonideal angle group at the final follow-up, and the ideal angle group had a smaller dCSA compared with the nonideal angle group (P<0.05).

CONCLUSIONS

The biomechanical balance of occipitocervical region in patients with occipitocervical diseases with different pathogenesis is different. On the basis of the different types of occipitocervical diseases, an appropriate range of OC2A and POCA should be selected by the surgeon during OCF, which can further improve the clinical efficacy and reduce the loss of the lower cervical curvature after surgery.

Can measuring passive neck muscle stiffness in whiplash injury patients help detect false whiplash claims?

BACKGROUND

Whiplash injury of the cervical spine is the most common injury after a car accident and in 25% of patients it progresses into chronic neck pain.

AIM OF THE STUDY

To investigate the difference in neck muscle stiffness using shear wave ultrasound elastography between subjects who suffered an uncomplicated whiplash injury and a control group. Possible recognition of patients who insist on physical therapy in order to support their false whiplash injury claims.

METHODS

This study included 75 whiplash injury patients and 75 control subjects. Trapezius, splenius capitis and sternocleidomastoid muscles were examined by ultrasound shear wave elastography.

RESULTS

Increased muscle stiffness was noticed in trapezius muscle bilaterally in the whiplash group when compared to the control group (p < 0.001; right 57.47 ± 13.82 kPa vs. 87.84 ± 23.23 kPa; left 54.4 ± 12.68 kPa vs. 87.21 ± 26.47 kPa). Muscle stiffness in splenius capitis and sternocleidomastoid muscles was not suitable for analysis because of asymmetrical data distribution. Patients with less than 76 kPa of muscle stiffness in trapezius muscle are unlikely to belong in whiplash injury group (sensitivity 90% for right and 97% for left trapezius muscle, specificity 72% and 73%, respectively).

CONCLUSION

Patients measuring below 76 kPa of muscle stiffness in the trapezius muscle might have no whiplash injury. Further follow-up of the patients measuring higher than cut-off value might be beneficial for detecting patients with prolonged neck muscle spasm that can lead to chronic cervical pain syndrome.

Differences of Spinal Curvature, Thoracic Mobility, and Respiratory Strength Between Chronic Neck Pain Patients and People Without Cervical Pain

OBJECTIVE

To investigate the differences of spinal curvature, thoracic sagittal mobility, and respiratory strength between patients with chronic neck pain (CNP) and people without cervical pain, and to determine the correlation between respiratory strength and thoracic mobility in CNP patients.

METHODS

A total of 78 participants were finally included in this study, of whom 30 had no cervical pain and 48 had CNP. The Neck Disability Index (NDI), cervical lordotic curvature, thoracic kyphotic curvature, thoracic sagittal range of motion (ROM), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP) were measured and analyzed.

RESULTS

In males, thoracic sagittal ROMMEP-MIP and MEP showed a significant difference between the no cervical pain group and the CNP group. In females, thoracic kyphotic curvature, thoracic sagittal ROMMEP-MIP, MIP, and MEP were significantly different between the no cervical pain group and the CNP group. Thoracic kyphotic curvature was significantly correlated with MEP and MIP in all population groups, and significantly correlated with NDI in the female group. Thoracic sagittal ROMMEP-MIP had a significant linear relationship with NDI, MEP, and MIP in all population groups.

CONCLUSION

The thoracic mobility during forced respiration was reduced in patients with CNP and was correlated with respiratory strength. Changes in the biomechanics of the cervicothoracic spine and rib cage due to CNP may contribute to impairment of respiratory strength.

Fatty infiltration of the cervical extensor musculature, cervical sagittal balance, and clinical outcomes: An analysis of operative adult cervical deformity patients

PURPOSE

To assess preliminary associations between fatty-infiltration (FI) of cervical spine extensor musculature, cervical sagittal balance, and clinical outcomes in cervical deformity (CD) patients.

METHODS

Operative CD patients (C2-C7 Cobb > 10°, CL > 10°, cSVA > 4 cm, or CBVA > 25°) with pre-operative (BL) MRIs and 1-year (1Y) post-operative MRIs or CTs were assessed for fatty-infiltration of cervical extensor musculature, using dedicated imaging software at each C2-C7 intervertebral level and the apex of deformity (apex). FI was gauged as a ratio of fat-free-muscle-cross-sectional-area (FCSA) over total-muscle-CSA (TCSA), with lower ratio values indicating greater FI. BL-1Y associations between FI, sagittal alignment, and clinical outcomes were assessed using appropriate parametric and non-parametric tests.

RESULTS

22 patients were included (Age 59.22, 71.4%F, BMI 29.2, CCI:0.75, Frailty: 0.43). BL deformity presentation: TS-CL: 29.0°, C2-C7 Sagittal Cobb:-1.6°, cSVA:30.4 mm. No correlations were observed between BL fatty-infiltration, sagittal alignment, frailty, or clinical outcomes (p > 0.05). Following surgical correction, C2-C7 (BL: 0.59 vs 1Y:0.67, p = 0.005) and apex (BL: 0.59 vs. 1Y: 0.66, p = 0.33) fatty-infiltration decreased. Achievement of lordotic curvature correlated with C2-C7 fatty infiltration reduction (R_s: 0.495, p < 0.05), and patients with residual postoperative TS-CL and cSVA malalignment were associated with greater apex fatty-infiltration (R_s: -0.565, -0.561; p < 0.05). C2-C7 FI improvement was associated with NRS back pain reduction (R_s: -0.630, p < 0.05), and greater apex fatty-infiltration at BL was associated with minor perioperative complication occurrence (R_s: 0.551, p = 0.014).

CONCLUSIONS

Deformity correction and sagittal balance appear to influence the reestablishment of cervical muscle tone from C2-C7 and reduction of back pain for severely frail CD patients. This analysis helps to understand cervical extensor musculature's role amongst CD patients.

Radiographic measurements of cervical alignment, fusion and subsidence after ACDF surgery and their impact on clinical outcome

BACKGROUND

Some recent studies indicate correlations between cervical alignment and clinical outcome after anterior cervical discectomy and fusion (ACDF) surgery. However, there still are no established criteria for the interpretation of alignment, fusion and subsidence in relation to clinical outcome.

METHODS

A retrospective analysis of 208 radiographs of patients following ACDF with stand-alone PEEK cage implantation was performed. The measurements were obtained on plain radiographs in lateral and anteroposterior projections as well as flexion/extension radiographs. Cervical alignment was measured using the Gore, Laing and Cobb methods; fusion was evaluated by an assortment of radiographic hallmarks: the presence of bridging bone, the Cobb angle and the distances between the tips and bases of the spinous processes of the operated segments, respectively. For assessment of subsidence, we used the Mochida method in addition to ventral and dorsal segmental height reduction. Correlation analysis between the different radiological characteristics and clinical outcome at a minimum follow-up of 12 months was conducted.

RESULTS

Two hundred and eight patients were evaluated for alignment, fusion and subsidence. Cervical alignment using the Gore and Cobb methods correlated among each other, but failed to exhibit significant correlation with clinical outcome. Interpretation of fusion rates varied greatly (43.9 to 89.4%) depending on the criteria used. Pearson coefficients between radiographic presence of pseudarthrosis and the measurements of the spinous process distances (0.595; p < 0.001), the Cobb angles (0.187; p = 0.007) and the presence of bridging bone (0.224; p < 0.001) each exhibited statistical significance. None of the methods employed significantly correlated with clinical outcome. Regarding subsidence, we found rates of 62%, 48% and 27% using the Mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between pairs of Mochida/ventral (r = 0.39; p = 0.66) and Mochida/dorsal (r = 0.007; p = 0.921) height reduction assessment methods were weak and no significant correlation between subsidence rates and clinical outcome was shown.

CONCLUSION

All measured parameters varied depending in the measurement method used. This was most pronounced for fusion. There was a moderate positive correlation between neck pain and subsidence as measured by the Mochida method.

Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis

PURPOSE

The purpose of the present study was to validate a new spinal sagittal classification.

METHODS

We retrospectively included 105 consecutive AIS patients who underwent posterior spinal fusion. Preoperative long-standing EOS radiographs were available on all patients. Patients were classified according to the four suggested sagittal patterns: type 1, 2a, 2b or 3. Several predetermined sagittal parameters were compared between the groups.

RESULTS

The mean preoperative Cobb angle was 64° ± 12°, and 73% of the patients were female. Of 105 patients, 51 were type 1, 14 were type 2a, one was type 2b and 39 were type 3. The distribution of the four sagittal patterns was significantly different compared with the original publication (p < 0.05). However, the two study populations were comparable in terms of Lenke and Roussouly types (p = 0.49 and 0.47, respectively). In our study population, the sagittal groups differed significantly in terms of thoracic kyphosis, length of thoracic and lumbar curves, lumbar lordosis, thoracic slope, C7 slope, pelvic incidence and sacral slope (p < 0.05).

CONCLUSION

The distribution of the four sagittal patterns varies between AIS cohorts. Type 2b was rare, which limits the clinical applicability. Contrary to the original publication, we found that the spinopelvic parameters lumbar lordosis, pelvic incidence and sacral slope were significantly different between the Abelin-Genevois types. Hence, the corrective surgical strategy may need to incorporate these spinopelvic parameters to achieve a balanced spine requiring a minimum of energy expenditure. These slides can be retrieved under Electronic Supplementary Material.

Importance of the Occipitoaxial Angle and Posterior Occipitocervical Angle in Occipitocervical Fusion

OBJECTIVE

To observe the effects of occipitoaxial angle (O-C2 angle, OC2A) and posterior occipitocervical angle (POCA) selection on postoperative clinical efficacy and lower cervical curvature in patients with acute acquired atlantoaxial dislocation after occipitocervical fusion (OCF).

METHODS

A total of 150 healthy subjects without cervical disease (healthy group) were randomly selected based on gender and age. Three spine surgeons measured the OC2A and POCA of the healthy group and averaged the values. A total of 30 patients with an average age of 51.0 years (range, 18-70 years; 16 male and 14 female) with trauma or rheumatoid arthritis (disease group) who underwent occipitocervical fusion (OCF) for atlantoaxial dislocation between January 2012 and June 2016 were reviewed. OC2A, POCA, and cervical spinal angle (CSA) were measured postoperative/soon after surgery and ambulation, and at the final follow-up visit. The preoperative and final follow-up visual analog scale (VAS), Japanese orthopedics association score (JOA), neck disability index (NDI), and dCSA (change of CSA from postoperative/soon after surgery and ambulation to final follow-up) were recorded.

RESULTS

The values of OC2A and POCA in 150 healthy subjects were 14.5° ± 3.7° and 108.2° ± 8.1°, respectively, and the 95% confidence interval (CI) were 7.2°-21.8° and 92.3°-124.0°, respectively. There was a negative correlation between OC2A and POCA (r = -0.386, P < 0.001). There were 18 patients (group one) of ideal OC2A and POCA (both within 95% CI of the healthy group) postoperative/soon after surgery and ambulation with a mean follow-up time of 26.3 ± 20.9 months in disease group. The remaining patients (group two) with a mean follow-up time of 31.3 ± 21.3 months. There was no statistically significant difference in the baseline data as well as pre-operative outcomes, including VAS score, JOA score, and NDI between the two groups. Likewise, the post-operative outcomes in final follow-up, including VAS and JOA score, had no distinct difference in the two groups. However, NDI (11.0 ± 2.9) in group two at the final follow-up was significantly higher than that in group one (7.0 ± 2.3) (P < 0.001). And group two showed statistically greater dCSA (5.9 ± 7.5°) than group one (-2.3° ± 6.2°) (P = 0.003).

CONCLUSIONS

The negative correlation between OC2A and POCA plays an important role in maintaining the biodynamic balance of the occipital-cervical region. OC2A and POCA should be controlled of a normal population in patients with acute acquired atlantoaxial dislocation during OCF, which can further improve the clinical efficacy and prevent loss of lower cervical curvature after surgery.