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Romani MD, Zhang HQ, Gao QL, Liu SH, Deng A. Cervical Sagittal Alignment and Related Factor Analysis and Prediction Model in Patients Undergoing Revision Surgery After Anterior Cervical Fusion. J Am Acad Orthop Surg 2024; 32:e585-e595. [PMID: 38595101 PMCID: PMC11111316 DOI: 10.5435/jaaos-d-23-00565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 02/03/2024] [Accepted: 02/17/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Patients with myelopathy or radiculopathy commonly undergo anterior cervical fusion surgery (ACFS), which has a notable failure rate on occasion. The goal of this study was to compare revision and nonrevision surgery patients in cervical sagittal alignment (CSA) subsequent to ACFS; additionally, to identify the best CSA parameters for predicting clinical outcome after ACFS; and furthermore, to create an equation model to assist surgeons in making decisions on patients undergoing ACFS. METHODS The data of 99 patients with symptomatic cervical myelopathy/radiculopathy who underwent ACFS were analyzed. Patients were divided into group A (underwent revision surgery after the first surgery failed) and group B (underwent only the first surgery). We measured and analyzed both preoperative and postoperative CSA parameters, including C2 slope, T1 slope, cervical lordosis C2-C7 (CL), C2-C7 sagittal vertical axis (C2C7 SVA), occiput-C2 lordosis angle (C0-C2), and chin brow vertical angle, and we further computed the correlation between the CSA parameters and created a prediction model. RESULTS The (T1S-CL)-C2S mismatch differed significantly between groups A and B ([9.95 ± 9.95] 0 , [3.79 ± 6.58] 0 , P < 0.05, respectively). A significant correlation was observed between C2 slope and T1CL in group B relative to group A postoperatively (R 2 = 0.42 versus R 2 = 0.09, respectively). Compared with group B, patients in group A had significantly higher C2C7SVA values, more levels of fusion, and more smokers. The sensitivity, specificity, accuracy, and discrimination of the model were, respectively, 73.5%, 84%, 78.8%, and 85.65%. CONCLUSION The causes of revision surgery in cervical myelopathic patients after anterior cervical corpectomy and fusion/anterior cervical diskectomy and fusion are multifactorial. (T1S-CL)-C2S mismatch and high C2C7SVA are the best cervical sagittal parameters that increase the odds of revision surgery, and the effect is more enhanced when comorbidities such as smoking, low bone-mineral density, and increased levels of fusion are taken into account.
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Affiliation(s)
- Manini Daudi Romani
- From the Department of spine surgery and Orthopedics, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, Deng), and the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, and Deng)
| | - Hong-Qi Zhang
- From the Department of spine surgery and Orthopedics, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, Deng), and the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, and Deng)
| | - Qi-Le Gao
- From the Department of spine surgery and Orthopedics, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, Deng), and the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, and Deng)
| | - Shao-Hua Liu
- From the Department of spine surgery and Orthopedics, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, Deng), and the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, and Deng)
| | - Ang Deng
- From the Department of spine surgery and Orthopedics, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, Deng), and the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (Romani, Zhang, Qi-Le Gao, Liu, and Deng)
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Henao Romero S, Sierra Peña JA, Diaz Orduz RC, Berbeo-Calderon ME. Horizontal Gaze Assessment: An Extensive Narrative Review. World Neurosurg 2024:S1878-8750(24)00788-5. [PMID: 38750886 DOI: 10.1016/j.wneu.2024.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE Bipedalism was a significant milestone in the evolutionary development of Homo sapiens sapiens, influencing neocortical evolution and subsequent behavioral changes. Coordinated visual and sensory inputs are crucial for posture, environmental interaction, and surgical planning, with horizontal gaze being a pivotal parameter. This narrative review aims to explore various geometric measures used to assess horizontal gaze in patients, highlighting their applications in surgical planning. METHODS A literature review was conducted in indexed databases using Mesh terms like "Cervical Vertebrae" and "Visual Fields" along with keywords such as "horizontal gaze" and "sagittal spine parameters." Among 477 initially identified articles, 41 were selected for inclusion after rigorous filtering. RESULTS The most recognized method for assessing horizontal gaze is the Chin Brow Vertical Angle (CBVA), initially described in patients with ankylosing spondylitis. Clinical photography is employed as a tool for CBVA calculation, while other measures like McGregor slope and Slope of the Line of Sight have been considered as alternatives to CBVA. Each method presents its unique advantages and limitations. CONCLUSIONS This review highlights the need for further research into horizontal gaze measurement methods. Developing novel approaches to determine horizontal gaze can significantly enhance surgical planning and, consequently, improve patient outcomes. The ongoing exploration of these geometric measures offers promising prospects for advancing the field and optimizing patient care.
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Affiliation(s)
- Sara Henao Romero
- Department of Neurosurgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia; Neurosurgery research seedbed, Pontificia Universidad Javeriana, Bogotá, Colombia.
| | | | - Roberto Carlos Diaz Orduz
- Department of Neurosurgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
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Zhang Z, Wang J, Ge R, Guo C, Liang Y, Liu H, Xu S. A novel classification that defines the normal cervical spine: an analysis based on 632 asymptomatic Chinese volunteers. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:155-165. [PMID: 37880410 DOI: 10.1007/s00586-023-07997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The "normal" cervical spine may be non-lordotic shapes and the cervical spine alignment targets are less well established. So, the study was to propose novel classification for cervical spine morphologies with Chinese asymptomatic subjects, and to address cervical balance status based on the classification. METHOD An overall 632 asymptomatic individuals on cervical spine were selected from January 2020 to December 2022, with six age groups from 20-30 year to 70 plus group. Cervical alignment contained C2-7 cervical lordosis (C2-7 CL) and T1 slope (T1S), together with C1-2 CL, C2-4 CL, C5-7 CL, C2S, cervical sagittal vertical axis (CSVA), thoracic inlet angle (TIA) and neck tilt (NT). C2-7 cervical lordosis was regarded as primary outcomes. To identify groups with similar cervical alignment parameters, a 2-step cluster analysis was performed. RESULTS C2-7 CL, T1S, CSVA, TIA and NT increased by age and mean value of them were larger in male than female group. Four unique clusters of female lordotic cluster, female kyphotic cluster, male lordotic cluster and male kyphotic cluster were classified mainly based on gender and C2-C7 CL. T1S was the independent influencing factor for C2-7 CL in all individuals and C2-7 CL = -28.65 + 0.57 × TIA, which varied from clusters. Although interactions among cervical parameters, it showed the alignment was more coordinated in lordotic groups. CONCLUSIONS The cervical sagittal profile varied with age and gender. Four clusters were naturally classified based on C2-7 CL and gender. The cervical balance status was addressed by C2-7 CL = - 28.65 + 0.57 × TIA.
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Affiliation(s)
- Zixiao Zhang
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Jinyu Wang
- Qingdao Chengyang People's Hospital, No. 600 Changcheng Road, Chengyang District, Qingdao, Shandong, People's Republic of China
| | - Rile Ge
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Chen Guo
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Yan Liang
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Haiying Liu
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Shuai Xu
- Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China.
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Karabag H, Iplikcioglu AC. Upper and lower cervical alignment parameters measured on supine magnetic resonance imaging with the occipital slope as a key marker of cervical alignment. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:61-65. [PMID: 38644912 PMCID: PMC11029111 DOI: 10.4103/jcvjs.jcvjs_185_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives Cervical spine alignment is evaluated by measuring the cervical angles or parameters on standing plain radiography. In this study, we aimed to evaluate mainly the upper cervical alignment and the correlation between upper and lower cervical sagittal parameters measured on supine magnetic resonance imaging (MRI). Materials and Methods Cervical MRIs of 210 outpatients were reviewed to measure the upper and lower cervical sagittal parameters. Their mean values were compared with normative values measured on standing X-ray from the literature. Correlations between the parameters were analyzed using the Pearson's correlation coefficient. Results The C0 slope was correlated with all other parameters, except for the C2-7 sagittal vertical axis. The strongest correlations (r > 0.500) were between the CL and C2 slope, between the CO2 and C0 slope, and between the C2 slope and C0 slope. Conclusion On supine MRI, the C0 slope is a key marker of cervical spinal alignment. A strong correlation was observed between the C2 slope and C0 slope; therefore, the relationship between upper and lower cervical alignment could be assessed using slopes on MRI.
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Affiliation(s)
- Hamza Karabag
- Department of Neurosurgery, Faculty of Medicine, Harran University, Şanlıurfa, İstanbul, Turkey
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Rossanez R, de Rezende Pratali R, Smith JS, Nasreddine MA, Pereira da Silva Herrero CF. Internal Chain of Correlation of Sagittal Cervical Alignment in Asymptomatic Subjects. Global Spine J 2023; 13:2439-2445. [PMID: 35343268 PMCID: PMC10538324 DOI: 10.1177/21925682221087185] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cross-sectional observational study in a prospective cohort. OBJECTIVE To analyze the cervical alignment characteristics and their chain of correlation in a sample of asymptomatic individuals. METHODS Asymptomatic adults who had full spinal radiographs performed. Cervical radiographic parameters were measured, including upper cervical curvature (McGregor line-C2), lower cervical curvature (C2-C7), McGregor slope, and sagittal vertical axis from C2-C7 (CSVA) and T1-slope (T1S). Subjects were stratified by age into 3 groups (18-39 years, 40-59 years, and >60 years), and radiographic parameters were compared across age groups and based on sex. RESULTS 102 asymptomatic subjects (mean age, 50 years) were included. The T1S significantly increased with age, accompanied by an increase in C2-C7 lordosis. The cervical sagittal alignment, represented by CSVA, did not significantly differ based on age. There was a close correlation among the cervical sagittal parameters, such that the CSVA may be predicted based on the T1S and C2-C7 lordosis. Comparisons of the normative values identified in the present study with those reported in previous studies demonstrate variability in what constitutes normal in different populations. CONCLUSION This analysis of cervical alignment in a sample of asymptomatic volunteers revealed that with increasing age there is an observed increase in the sagittal inclination of the base of the cervical spine (T1S) that is accompanied by an increase in cervical lordosis as a means of maintaining cervical sagittal alignment (CSVA). The variability in what constitutes normal values for cervical parameters suggests that further study is warranted using standardized methodologies across diverse populations.
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Affiliation(s)
- Roberto Rossanez
- Health Sciences Applied to the Locomotor System Graduate Program, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, Brazil
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Mohamed Ahmed Nasreddine
- Spine Surgery Group, Hospital Do Servidor Público Estadual de São Paulo (HSPE), São Paulo, Brazil
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Ladd BM, Martin CT, Sembrano JN, Jones KE, Polly DW, Hunt MA. Odontoid Fracture as Proximal Junctional Failure in Patients With Multilevel Spine Fusions. Global Spine J 2023; 13:781-786. [PMID: 33973486 DOI: 10.1177/21925682211008833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture. METHODS We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval. RESULTS Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment. CONCLUSION In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.
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Affiliation(s)
- Bryan M Ladd
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Jonathan N Sembrano
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kristen E Jones
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - David W Polly
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Matthew A Hunt
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
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Algarni N, Dea N, Evaniew N, McIntosh G, Jacobs BW, Paquet J, Wilson JR, Hall H, Bailey CS, Weber MH, Nataraj A, Attabib N, Rampersaud YR, Cadotte DW, Stratton A, Christie SD, Fisher CG, Charest-Morin R. Does Ending a Posterior Construct Proximally at C2 Versus C3 Impact Patient Reported Outcomes in Degenerative Cervical Myelopathy Patients up to 24 months After the Surgery? Global Spine J 2023:21925682231166605. [PMID: 36960878 DOI: 10.1177/21925682231166605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The primary objective was to evaluate the impact of the upper instrumented level (UIV) being at C2 vs C3 in posterior cervical construct on patient reported outcomes (PROs) up to 24 months after surgery for cervical degenerative myelopathy (DCM). Secondary objectives were to compare operative time, intra-operative blood loss (IOBL), length of stay (LOS), adverse events (AEs) and re-operation. METHODOLOGY Patients who underwent a posterior cervical instrumented fusion (3 and + levels) with a C2 or C3 UIV, with 24 months follow-up were analyzed. PROs (NDI, EQ5D, SF-12 PCS/MCS, NRS arm/neck pain) were compared using ANCOVA. Operative duration, IOBL, AEs, and re-operation were compared. Subgroup analysis was performed on patient presenting with pre-operative malalignment (cervical sagittal vertical axis ≥40 mm and/or T1slope- cervical lordosis >15°). RESULTS 173 patients were included, of which 41 (24%) had a C2 UIV and 132 (76%) a C3 UIV. There was no statistically significant difference between the groups for the changes in PROs up to 24 months. Subgroup analysis of patients with pre-operative malalignment showed a trend towards greater improvement in the NDI at 12 months with a C2 UIV (P = .054). Operative time, IOBL and peri-operative AEs were more in C2 group (P < .05). There was no significant difference in LOS and re-operation (P > .05). CONCLUSION In this observational study, up to 24 months after surgery for posterior cervical fusion in DCM greater than 3 levels, PROs appear to evolve similarly.
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Affiliation(s)
- Nizar Algarni
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver BC, Canada
| | - Nathan Evaniew
- Combined Neurosurgical and Orthopedic Spine Program, University of Calgary, Calgary, AB, Canada
| | - Greg McIntosh
- Canadian Spine Outcomes and Research Network, Markdale, ON, Canada
| | - Bradley W Jacobs
- Combined Neurosurgical and Orthopedic Spine Program, University of Calgary, Calgary, AB, Canada
| | - Jérome Paquet
- Centre de Recherche CHU de Quebec, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | - Jefferson R Wilson
- Divisions of Orthopaedic and Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher S Bailey
- Department of Orthopedics Surgery, London Health Science Centre, Western University, London, ON, Canada
| | - Michael H Weber
- Department of Orthopedics Surgery, McGill UniversityHealth Centre, Montreal, QC, Canada
| | - Andrew Nataraj
- Division of Neurosurgery, Department of Surgery, University of AlbertaHospital, Edmonton, AB, Canada
| | - Najmedden Attabib
- Canada East Spine Centre, Division of Neurosurgery, Horizon Health Network, Saint John, NB, Canada
| | | | - David W Cadotte
- Combined Neurosurgical and Orthopedic Spine Program, University of Calgary, Calgary, AB, Canada
| | - Alexandra Stratton
- Department of Orthopedics Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sean D Christie
- Division of Neurosurgery, Dalhousie University, Halifax, NS, Canada
| | - Charles G Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver BC, Canada
| | - Raphaële Charest-Morin
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver BC, Canada
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Association between the Phase Angle and the Severity of Horizontal Gaze Disorder in Patients with Idiopathic Dropped Head Syndrome: A Cross-Sectional Study. Medicina (B Aires) 2023; 59:medicina59030526. [PMID: 36984527 PMCID: PMC10056395 DOI: 10.3390/medicina59030526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Background and Objectives: The phase angle, calculated by bioelectrical impedance analysis, can help elucidate the pathology of patients with idiopathic dropped head syndrome (IDHS) and explain the motor dysfunction associated with the horizontal gaze disorder. The aim of this study was to clarify the characteristics of phase angle in IDHS patients and the relationship between the phase angle and the severity of horizontal gaze disorder. Materials and Methods: This cross-sectional study included 43 female patients with IDHS and 69 healthy female volunteers. A multi-frequency segmental body composition analyzer was used to calculate body composition parameters, including whole-body and lower extremity phase angles. Propensity score (PS) matching analysis was performed to compare the body composition parameters between the IDHS and healthy groups. Variables that determine the PS were identified by correlation analysis, using the whole-body phase angle as the dependent variable. In addition, correlation analysis was performed between the severity of horizontal gaze disorder as assessed by McGregor’s slope (McGS), phase angle, and other body composition parameters. Results: Unadjusted group comparisons showed no significant difference in whole-body and lower extremity phase angles between the IDHS and healthy groups. PS matching created a total of 38 matched pairs for age, height, and fat-free mass index. Although the comparison between groups of matched samples showed no significant difference in the whole-body phase angle, the lower extremity phase angle in the IDHS group was significantly lower than that in the healthy group (p = 0.033). Correlation analysis showed significant negative correlations only between McGS and whole-body (r = −0.31, p = 0.043) and lower extremity phase angle (r = −0.39, p = 0.009) in the IDHS group. Conclusions: Abnormal body composition of the lower extremities were observed in IDHS patients. Furthermore, it was suggested that horizontal gaze disorder in IDHS patients is associated with whole-body and lower extremity phase angles.
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İplikçioğlu AC, Karabağ H. Analysis of Components of Upper Cervical Lordosis in Asymptomatic Lordotic and Kyphotic Subjects. World Neurosurg 2023; 171:e852-e858. [PMID: 36608798 DOI: 10.1016/j.wneu.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023]
Abstract
BACKGROUND Upper cervical lordosis (CL) can be divided into 2 components: C2 slope (C2S) and McGregor slope (MGS) or C0-1 and C1-2 angles. The aim of this study was to investigate the components of upper CL in asymptomatic kyphotic and lordotic subjects. METHODS CL, C0-2 Cobb angle, MGS, C2S, C1 Slope, C0-1 Cobb angle, C1-2 Cobb angle, T1 slope angular parameters, and the C2-7 sagittal vertical axis distance of 78 asymptomatic subjects were measured. RESULTS Sixty subjects had lordotic curvature and 18 had kyphotic curvature. There was a significant difference between the kyphotic and lordotic groups in all parameters, except for C0-1 Cobb angle and C2-7 sagittal vertical axis. In lordotic subjects, MGS and C2S accounted for 58% and 42% of the C0-2 angle, whereas in kyphotic subjects, 86% of C0-2 was accounted for by C2S. There was a strong negative correlation between C2S and MGS. CONCLUSIONS In asymptomatic subjects, as CL decreases, MGS decreases, C2S increases, and the C0-2 angle turns down on the horizontal plane to maintain the horizontal gaze. Turning down the C0-2 angle is more important than its value for maintaining horizontal gaze; thus, the slopes (MGS and C2S) can better represent the upper and lower cervical alignment than angle values can. The relationship between upper and lower cervical alignment should be evaluated in terms of slope angles rather than simple angles. The lack of significant difference between the C0-1 angles in the kyphotic and lordotic groups suggests that only the C1-2 angle is involved in the compensatory mechanism for the horizontal gaze.
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Affiliation(s)
| | - Hamza Karabağ
- Department of Neurosurgery, Harran Üniversity, Şanlıurfa, Turkey.
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Virk S, Lafage R, Elysee J, Passias P, Kim HJ, Qureshi S, Lafage V. Cervical Paraspinal Muscle Fatty Infiltration is Directly Related to Extension Reserve in Patients With Cervical Spine Pathology. Clin Spine Surg 2023; 36:E22-E28. [PMID: 35759773 DOI: 10.1097/bsd.0000000000001356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/18/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN/SETTING Retrospective review of a prospectively collected database. OBJECTIVE The objective of this study was to determine the relationship between paracervical muscle area, density, and fat infiltration and cervical alignment among patients presenting with cervical spine pathology. BACKGROUND CONTEXT The impact of cervical spine alignment on clinical outcomes has been extensively studied, but little is known about the association between spinal alignment and cervical paraspinal musculature. METHODS We examined computed tomography scans and radiographs for patients presenting with cervical spine pathology. The posterior paracervical muscle area, density, and fat infiltration was calculated on axial slices at C2, C4, C6, and T1. We measured radiographic parameters including cervical sagittal vertical axis, cervical lordosis, T1 slope (T1S), range of motion of the cervical spine. We performed Pearson correlation tests to determine if there were significant relationships between muscle measurements and alignment parameters. RESULTS The study included 51 patients. The paracervical muscle area was higher for males at C2 ( P =0.005), C4 ( P =0.001), and T1 ( P =0.002). There was a positive correlation between age and fat infiltration at C2, C4, C6, and T1 (all P <0.05). The cervical sagittal vertical axis positively correlated with muscle cross-sectional area at C2 ( P =0.013) and C4 ( P =0.013). Overall cervical range of motion directly correlated with muscle density at C2 ( r =0.48, P =0.003), C4 ( r =0.41, P =0.01), and C6 ( r =0.53. P <0.001) and indirectly correlated with fat infiltration at C2 ( r =-0.40, P =0.02), C4 ( r =-0.32, P =0.04), and C6 ( r =-0.35, P =0.02). Muscle density correlated directly with reserve of extension at C2 ( r =0.57, P =0.009), C4 ( r =0.48, P =0.037), and C6 ( r =0.47, P =0.033). Reserve of extension indirectly correlated with fat infiltration at C2 ( r =0.65, P =0.006), C4 ( r =0.47, P =0.037), and C6 ( r =0.48, P =0.029). CONCLUSIONS We have identified specific changes in paracervical muscle that are associated with a patient's ability to extend their cervical spine.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedic Surgery, Northwell Health, Great Neck
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery
| | - Jonathan Elysee
- Department of Orthopedic Surgery, Hospital for Special Surgery
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery
| | - Sheeraz Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery
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Establishment of an Individualized Distal Junctional Kyphosis Risk Index following the Surgical Treatment of Adult Cervical Deformities. Spine (Phila Pa 1976) 2023; 48:49-55. [PMID: 35853172 DOI: 10.1097/brs.0000000000004372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/06/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of a multicenter comprehensive cervical deformity (CD) database. OBJECTIVE To develop a novel risk index specific to each patient to aid in patient counseling and surgical planning to minimize postop distal junctional kyphosis (DJK) occurrence. BACKGROUND DJK is a radiographic finding identified after patients undergo instrumented spinal fusions which can result in sagittal spinal deformity, pain and disability, and potentially neurological compromise. DJK is considered multifactorial in nature and there is a lack of consensus on the true etiology of DJK. MATERIALS AND METHODS CD patients with baseline (BL) and at least one-year postoperative radiographic follow-up were included. A patient-specific DJK score was created through use of unstandardized Beta weights of a multivariate regression model predicting DJK (end of fusion construct to the second distal vertebra change in this angle by <-10° from BL to postop). RESULTS A total of 110 CD patients included (61 yr, 66.4% females, 28.8 kg/m 2 ). In all, 31.8% of these patients developed DJK (16.1% three males, 11.4% six males, 62.9% one-year). At BL, DJK patients were more frail and underwent combined approach more (both P <0.05). Multivariate model regression analysis identified individualized scores through creation of a DJK equation: -0.55+0.009 (BL inclination)-0.078 (preinflection)+5.9×10 -5 (BL lowest instrumented vertebra angle) + 0.43 (combine approach)-0.002 (BL TS-CL)-0.002 (BL pelvic tilt)-0.031 (BL C2 - C7) + 0.02 (∆T4-T12)+ 0.63 (osteoporosis)-0.03 (anterior approach)-0.036 (frail)-0.032 (3 column osteotomy). This equation has a 77.8% accuracy of predicting DJK. A score ≥81 predicted DJK with an accuracy of 89.3%. The BL reference equation correlated with two year outcomes of Numeric Rating Scales of Back percentage ( P =0.003), reoperation ( P =0.04), and minimal clinically importance differences for 5-dimension EuroQol questionnaire ( P =0.04). CONCLUSIONS This study proposes a novel risk index of DJK development that focuses on potentially modifiable surgical factors as well as established patient-related and radiographic determinants. The reference model created demonstrated strong correlations with relevant two-year outcome measures, including axial pain-related symptoms, occurrence of related reoperations, and the achievement of minimal clinically importance differences for 5-dimension EuroQol questionnaire.
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12
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Louie PK, Sheikh Alshabab B, McCarthy MH, Virk S, Dowdell JE, Steinhaus ME, Lovecchio F, Samuel AM, Morse KW, Schwab FJ, Albert TJ, Qureshi SA, Iyer S, Katsuura Y, Huang RC, Cunningham ME, Yao YC, Weissmann K, Lafage R, Lafage V, Kim HJ. Classification system for cervical spine deformity morphology: a validation study. J Neurosurg Spine 2022; 37:865-873. [PMID: 35901688 DOI: 10.3171/2022.5.spine211537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology. METHODS The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience. RESULTS The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559-0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606-0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531-0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%. CONCLUSIONS This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.
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Affiliation(s)
- Philip K Louie
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,2Department of Neurosurgery, Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington
| | - Basel Sheikh Alshabab
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael H McCarthy
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,3Department of Orthopaedic Surgery, Indiana Spine Group, University of Indiana, Carmel, Indiana
| | - Sohrab Virk
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - James E Dowdell
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael E Steinhaus
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,5Spine Institute, MountainStar Healthcare, Murray, Utah
| | - Francis Lovecchio
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Andre M Samuel
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Kyle W Morse
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank J Schwab
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Todd J Albert
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sheeraz A Qureshi
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sravisht Iyer
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yoshihiro Katsuura
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,6Department of Orthopedics, Adventist Health, Willits, California
| | - Russel C Huang
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Matthew E Cunningham
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yu-Cheng Yao
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,7Department of Orthopedics, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Karen Weissmann
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,8Department of Orthopedics and Traumatology, University of Chile, Santiago, Chile
| | - Renaud Lafage
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Virginie Lafage
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Han Jo Kim
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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13
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Lee JK, Hyun SJ, Kim KJ. Reciprocal Changes in the Whole-Body Following Realignment Surgery in Adult Spinal Deformity. Asian Spine J 2022; 16:958-967. [PMID: 35527534 PMCID: PMC9827204 DOI: 10.31616/asj.2021.0451] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/03/2022] [Indexed: 01/11/2023] Open
Abstract
The idea of the global balance of spine stems from Jean Dubousset, who first introduced the concept of cone of economy. Through the compensatory mechanisms, the human body maintains an upright posture and horizontal gaze in the setting of the spinal malalignment. Compensation takes place not only in the mobile spine segments, but also in the pelvis and lower extremities. Patients with a malalignment exhibit compensatory changes in the cervical hyper-lordosis, posterior pelvic shift, knee/ankle flexion, hip extension, and the pelvic retroversion. The advent of whole-body stereo radiography has yielded an improved understanding of global changes among the patients. Deformity-induced compensatory changes in the sagittal alignment could be resolved reciprocally after the surgical correction of the malalignment. Thoracolumbar realignment surgery restores the pathologic compensatory changes in the unfused spinal segments, pelvis, and the lower extremities. Similarly, reciprocal changes in the thoracolumbar spine may harmonize global sagittal alignment after the cervical reconstruction. This study reviews the compensatory mechanisms and reciprocal changes in global sagittal alignment caused by the surgical correction and highlights, the factors that should be considered while assessing a patient's compensatory status.
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Affiliation(s)
- Jae-Koo Lee
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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14
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Passias PG, Krol O, Moattari K, Williamson TK, Lafage V, Lafage R, Kim HJ, Daniels A, Diebo B, Protopsaltis T, Mundis G, Kebaish K, Soroceanu A, Scheer J, Hamilton DK, Klineberg E, Schoenfeld AJ, Vira S, Line B, Hart R, Burton DC, Schwab FA, Shaffrey C, Bess S, Smith JS, Ames CP. Evolution of Adult Cervical Deformity Surgery Clinical and Radiographic Outcomes Based on a Multicenter Prospective Study: Are Behaviors and Outcomes Changing With Experience? Spine (Phila Pa 1976) 2022; 47:1574-1582. [PMID: 35797645 DOI: 10.1097/brs.0000000000004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time. SUMMARY OF BACKGROUND DATA As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown. MATERIALS AND METHODS Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time. RESULTS A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03). CONCLUSION Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Kevin Moattari
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Bassel Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Themistocles Protopsaltis
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank A Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | | | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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15
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Obo T, Fujishiro T, Mizutani M, Nakano A, Nakaya Y, Hayama S, Usami Y, Neo M. Segmental cervical instability does not drive the loss of cervical lordosis after laminoplasty in patients with cervical spondylotic myelopathy. Spine J 2022; 22:1837-1847. [PMID: 35724810 DOI: 10.1016/j.spinee.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND/CONTEXT Kyphotic deformity after cervical laminoplasty (CLP) often leads to unfavorable neurological recovery due to insufficient indirect decompression of the spinal cord. Existing literature has described that segmental cervical instability is a contraindication for CLP because it is a potential risk factor for kyphotic changes after surgery; however, this has never been confirmed in any clinical studies. PURPOSE To confirm whether segmental cervical instability was an independent risk factor for postoperative kyphotic change and to examine whether segmental cervical instability led to poor neurological outcomes after CLP for cervical spondylotic myelopathy (CSM). STUDY DESIGN/SETTING A retrospective study PATIENT SAMPLE: Patients who underwent CLP for CSM between January 2013 and January 2021 with a follow-up period of ≥1 year were enrolled. OUTCOME MEASURES Cervical radiographic measurements including C2-C7 lordosis (C2-7 angle), cervical sagittal vertical axis, C7 slope, flexion range of motion (fROM) and extension ROM (eROM) were assessed using neutral and flexion-extension views. Segmental cervical instability was classified into anterolisthesis (AL) of ≥2 mm displacement, retrolisthesis (RL) of ≥2 mm displacement, and translational instability (TI) of ≥3 mm translational motion. The amount of C2-7 angle loss at the follow-up period compared to the preoperative measurements was defined as cervical lordosis loss (CLL). Neurological outcomes were assessed using the recovery rate of the Japanese Orthopedic Association score (JOA-RR). METHODS CLL was compared among patients with and without segmental cervical instability. Further, multiple linear regression model for CLL was built for the evaluation with adjustment of the reported risks, including cervical sagittal vertical axis, C7 slope, fROM, eROM, and patient age together with AL, RL, and TI, as independent variables. The JOA-RR was also compared between patients with and without segmental cervical instability. RESULTS A total of 138 patients (mean age, 68.7 years; 65.9% male) were included in the analysis. AL, RL, and TI were found in 12 (8.7%), 33 (23.9%), and 16 (11.6%) patients, respectively. Comparisons among the groups showed that AL led to greater CLL; however, RL and TI did not. Multiple linear regression analysis revealed that greater CLL is significantly associated with greater fROM and smaller eROM (regression coefficient [β]=0.328, 95% confidence interval: 0.178 to 0.478, p<.001; β=-0.372, 95% confidence interval: -0.591 to -0.153, p=.001, respectively). However, there were no significant statistical associations in the AL, RL, and TI. Whereas, patients with AL tended to exhibit lower JOA-RR than those without AL (37.8% vs. 52.0%, p=.108). CONCLUSIONS Segmental cervical instability is not the definitive driver for loss of cervical lordosis after CLP in patients with CSM; thus, is not a contraindication in and of itself. However, it is necessary to consider the indications for CLP, according to individual cases of patients with AL on baseline radiograph, which is a sign of poor neurological recovery.
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Affiliation(s)
- Takuya Obo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan; Department of Orthopedic Surgery, First Towakai Hospital, 2-17, Miyano-machi, Takatsuki, Osaka, 569-0081, Japan
| | - Takashi Fujishiro
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan; Department of Orthopedic Surgery, First Towakai Hospital, 2-17, Miyano-machi, Takatsuki, Osaka, 569-0081, Japan.
| | - Masahiro Mizutani
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
| | - Atsushi Nakano
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
| | - Yoshiharu Nakaya
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
| | - Sachio Hayama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
| | - Yoshitada Usami
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686 Japan
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16
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Lafage R, Smith JS, Fong AM, Sheikh Alshabab B, Protopsaltis T, Klineberg EO, Mundis G, Passias PG, Gupta M, Shaffrey CI, Kim HJ, Bess S, Schwab F, Ames CP, Lafage V. Proximal and distal reciprocal changes following cervical deformity malalignment correction. J Neurosurg Spine 2022; 37:599-606. [PMID: 35523249 DOI: 10.3171/2022.2.spine211316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hyperextension of C0-2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0-2 hyperextension and improved clinical outcomes. METHODS A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2-7 and C0-2. The association between C2-7 correction and change in C0-2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2-7 percentiles. RESULTS Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2-7, -11.7° ± 18.2°; T1 slope-cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] -12.8 ± 71.2 mm), and hyperlordosis at C0-2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2-7 and C0-2, respectively, with an ROE of approximately 9° for each segment. Limited C0-2 ROM and ROE correlated with the Neck Disability Index (r = -0.371 and -0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2-7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0-2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to -49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0-2 ROM increased to 27.6° ± 8.1° and C2-7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2-7 lordosis significantly correlated with increased TK (r = -0.617, p < 0.001), decreased C0-2 (r = -0.747, p < 0.001), and increased C0-2 ROE (r = 0.550, p = 0.002). CONCLUSIONS CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0-2 ROE and TK and was also associated with improved clinical outcome.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 2Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Alex Moy Fong
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Basel Sheikh Alshabab
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | | | - Eric O Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | | | - Peter G Passias
- 4Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Munish Gupta
- 7Department of Orthopaedics, Washington University, St. Louis, Missouri
| | | | - Han Jo Kim
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 9Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | - Frank Schwab
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | - Christopher P Ames
- 10Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
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17
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Igawa T, Ishii K, Urata R, Suzuki A, Ui H, Ideura K, Isogai N, Sasao Y, Funao H. Association between the Horizontal Gaze Ability and Physical Characteristics of Patients with Dropped Head Syndrome. Medicina (B Aires) 2022; 58:medicina58040465. [PMID: 35454304 PMCID: PMC9032265 DOI: 10.3390/medicina58040465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Patients with dropped head syndrome exhibit weakness of the cervical paraspinal muscles. However, the relationship between horizontal gaze disorder and physical function remains unclear. This study aimed to examine and clarify this relationship. Materials and Methods: Ninety-six patients with dropped head syndrome were included. We measured the McGregor’s Slope and investigated physical characteristics, including cervical muscle strength, back muscle strength, and walking ability. Factor analysis was used to classify the characteristics of physical function, and a linear multiple regression analysis was used to evaluate independent variables explaining the variance in the McGregor’s Slope. The physical functions of DHS patients were classified into three categories by factor analysis: limb and trunk muscle strength, walking ability, and neck muscle strength. Results: The average value of the McGregor’s Slope was 22.2 ± 24.0 degrees. As a result of multiple regression analysis, walking speed (β = −0.46) and apex (β = −0.30) were extracted as significant factors influencing the McGregor’s Slope. Conclusions: Horizontal gaze disorders are not associated with cervical muscle strength but with the walking ability and the alignment type of dropped head syndrome.
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Affiliation(s)
- Tatsuya Igawa
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City 286-8520, Japan; (N.I.); (Y.S.); (H.F.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; (R.U.); (A.S.); (H.U.); (K.I.)
- Department of Physical Therapy, School of Health Science, International University of Health and Welfare, 2600-1, Kitakanemaru, Ohtawara 323-8501, Japan
- Correspondence: (T.I.); (K.I.); Tel.: +81-476-35-5600 (T.I. & K.I.)
| | - Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City 286-8520, Japan; (N.I.); (Y.S.); (H.F.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Correspondence: (T.I.); (K.I.); Tel.: +81-476-35-5600 (T.I. & K.I.)
| | - Ryunosuke Urata
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; (R.U.); (A.S.); (H.U.); (K.I.)
| | - Akifumi Suzuki
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; (R.U.); (A.S.); (H.U.); (K.I.)
| | - Hideto Ui
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; (R.U.); (A.S.); (H.U.); (K.I.)
| | - Kentaro Ideura
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; (R.U.); (A.S.); (H.U.); (K.I.)
| | - Norihiro Isogai
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City 286-8520, Japan; (N.I.); (Y.S.); (H.F.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Yutaka Sasao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City 286-8520, Japan; (N.I.); (Y.S.); (H.F.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City 286-8520, Japan; (N.I.); (Y.S.); (H.F.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
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Manlapaz M, Beresian J, Avitsian R. Airway Management in Cervical Spine Pathologies. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Passias P, Pierce K, Krol O, Lebovic J, Kummer N, Passfall L, Ahmad W, Naessig S, Diebo B. Do the newly proposed realignment targets bridge the gap between radiographic and clinical success in adult cervical deformity corrective surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:67-71. [PMID: 35386239 PMCID: PMC8978849 DOI: 10.4103/jcvjs.jcvjs_67_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Hypothesis: The myelopathy-based cervical deformity (CD) thresholds will associate with patient-reported outcomes and complications. Materials and Methods: This study include CD patients (C2-C7 Cobb > 10°, CL > 10°, cervical sagittal vertical axis > 4 cm, or CBVA > 25°) with BL and 1-year (1Y) data. Modifiers assessed low (L), moderate (M), and severe (S) deformity: CL (L: >3°; M:-21° to 3°; S: <‒21°), TS-CL (L: <26°; M: 26° to 45°; S: >45°), C2-T3 angle (L: >‒25°; M:-35° to-25°; S: <‒35°), C2 slope (L: <33°; M: 33° to 49°; S: >49°), MGS (L: >‒9° and < 0°; M: ‒12° to ‒9° or 0° to 19°; S: < ‒12° or > 19°), and frailty (L: <0.18; M: 0.18–0.27, S: >0.27). Means comparison and ANOVA assessed outcomes in the severity groups at BL at 1Y. Correlations found between modifiers assessed the internal relationship. Results: One hundred and four patients were included in the study (57.1 years, 50%, 29.3 kg/m2). Baseline S TS-CL, C2-T3, and C2S modifiers were associated with increased reoperations (P < 0.01), while S MGS, CL, and C2-T3 had increased estimated blood lost (>1000ccs, P < 0.001). S MGS and C2-T3 had more postop DJK (60%, P = 0.018). Improvement in TS-CL, C2S, C2-T3, and CL patients had better numeric rating scale (NRS) back (<5) and EuroQOL 5-Dimension questionnaire (EQ5D) at 1 year (P < 0.05). Improving the modifiers correlated strongly with each other (0.213–0.785, P < 0.001). Worsened TS-CL had increased NRS back scores at 1 year (9, P = 0.042). Worsened CL had increased 1-year modified Japanese Orthopedic Association (mJOA) (7, P = 0.001). Worsened C2-T3 had worse NRS neck scores at 1 year (P = 0.048). Improvement in all six modifiers (8.7%) had significantly better health-related quality of life (HRQL) scores at follow-up (EQ5D, NRS, and Neck Disability Index). Conclusions: Newly proposed CD modifiers based on mJOA were closely associated with outcomes. Improvement and deterioration in the modifiers significantly impacted the HRQL.
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Passias P, Alas H, Kummer N, Tretiakov P, Diebo B, Lafage R, Ames C, Line B, Klineberg E, Burton D, Uribe J, Kim H, Daniels A, Bess S, Protopsaltis T, Mundis G, Shaffrey C, Schwab F, Smith J, Lafage V, International Spine Study Group. Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:271-277. [PMID: 36263336 PMCID: PMC9574121 DOI: 10.4103/jcvjs.jcvjs_66_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), although patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD corrective surgery with regard to HK and hyperlordosis (HL). Objective: The objective of the study is to evaluate patterns in treatment for CD patients with baseline (BL) HK and HL and understand how extreme curvature of the spine may influence surgical outcomes. Materials and Methods: Operative CD patients with BL and 1-year (1Y) radiographic data were included in the study. Patients were stratified based on BL C2–C7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (−6.96 ± 21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (<−28.43°) depending on directionality. Patients within 1SD were considered control group. Results: 102 surgical CD patients (61 years, 65% F, 30 kg/m2) with BL and 1Y radiographic data were included. 20 patients met definitions for HK and 21 patients met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with posterior approach. Operative time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-SVA (10.8 vs. 7.0 vs. −47.8 mm, P = 0.001). HL patients had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had 3x revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL patients had higher cSVA and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK patients had higher McGregor's slope (MGS) (16.1° vs. 3.3°, P = 0.002) and C0–C2 Cobb (43.3° vs. 26.9°, P < 0.001), however, postoperative differences in MGS and C0–C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary CT (38.1%), UT (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1-year postoperative, perhaps due to undercorrection compared to kyphotic etiologies.
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Hey HWD, Lim JXY, Tan CS, Liu GKP, Wong HK. Audit and Comparison Between Radiographic Markers of Gaze Direction Using EOS Imaging - An Essential Step to Streamline Existing Methods. Spine (Phila Pa 1976) 2021; 46:E1202-E1210. [PMID: 34474453 DOI: 10.1097/brs.0000000000004213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study on prospectively implemented EOS protocol. OBJECTIVE This study aims to audit and compare existing radiological definitions of gaze direction-chin brow vertical angle (CBVA), McGregor slope (McGS), slope of line of sight (SLS), orbital-internal occipital protuberance (OIOP) slope angle, and Tangent to the hard palate (THP) in a neutral, healthy, and asymptomatic cohort. SUMMARY OF BACKGROUND DATA The ability to accurately define direction of gaze is the first step when striving for horizontal gaze restoration in any affected individual with rigid sagittal deformity. Yet, the radiological definition of gaze direction remains poorly standardized. METHODS Hundred healthy subjects who could achieve horizontal gaze underwent whole-body standing EOS radiographs taken under a strictly standardized protocol. Radiographic measurements of global spinal sagittal parameters and surrogate measures of horizontal gaze were analyzed and compared. RESULTS The mean age was 45 ± 15.9 years, with a balanced male-to-female-ratio. Their C7 SVA was -7.7 mm ± 24.8 mm, PI was 51.0o ± 11.4o, PI-LL was -0.9o ± 13.0o and T1-slope was 21.2o ± 9.2o. Measured horizontal gaze parameters were as follows: CBVA (1.07o ± 5.48o), McGS (-3.23o ± 5.63o), SLS (0.45o ± 5.34o), OIOP (5.03o ± 4.66o), THP (-0.17o ± 6.27o). CBVA correlated strongly with McGS (r = 0.679, P < 0.001), SLS (r = 0.592, P < 0.001), OIOP (r = 0.697, P < 0.001), and THP (r = -0.504, P < 0.001). OIOP had the lowest variance amongst all parameters and showed less variability compared to CBVA (SD 4.66 Var 21.69 vs. SD 5.48 Var 30.08, P = .012). Multivariate analysis showed that C2-7 angle was the only parameter found to be associated with OIOP values (P = 0.006). CONCLUSION OIOP is the least variable, and most robust radiological method in determining gaze direction. It uses easily recognizable anatomical landmarks and an angular criterion, which makes it advantageous both with x-rays or slot scanners.Level of Evidence: 3.
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Affiliation(s)
| | - Joel Xue Yi Lim
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Gabriel Ka Po Liu
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Hee Kit Wong
- Department of Orthopedic Surgery, National University of Singapore, Singapore
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Ogura Y, Dimar JR, Djurasovic M, Carreon LY. Etiology and treatment of cervical kyphosis: state of the art review-a narrative review. JOURNAL OF SPINE SURGERY 2021; 7:422-433. [PMID: 34734146 DOI: 10.21037/jss-21-54] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
Objective To provide state of the art review regarding cervical kyphosis. Background Cervical spine kyphosis has been increasingly common due to the growing elderly population. Clinicians should comprehensively understand its symptoms, biomechanics, etiology, radiographic evaluation, classification, and treatment options and complications of each treatment. Comprehensive review will help clinicians improve the management for patients with cervical kyphosis. Methods The available literature relevant to cervical kyphosis was reviewed. PubMed, Medline, OVID, EMBASE, and Cochrane were used to review the literature. Conclusions This article summarizes current concepts regarding etiology, evaluation, surgical treatment, complications and outcomes of cervical kyphosis. Major etiologies of cervical kyphosis include degenerative, post-laminectomy, and ankylosing spondylitis. Clinical presentations include neck pain, myelopathy, radiculopathy, and problems with horizontal gaze, swallowing and breathing. Cervical lordosis, C2-7 sagittal vertical axis, chin-brow to vertical angle, and T1 slope should be evaluated from upright lateral 36-inch film. The most widely used classification system includes a deformity descriptor and 5 modifiers. A deformity descriptor provides a basic grouping of the deformity consisting of five types, cervical, cervicothoracic, thoracic, coronal cervical deformity, and cranio-vertebral junction deformity. The 5 modifiers include C2-7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus cervical lordosis, myelopathy based on modified Japanese Orthopaedic Association score, and SRS-Schwab classification for thoracolumbar deformity. Current treatment options include anterior discectomy and fusion, anterior osteotomy, Smith-Peterson osteotomy, pedicle subtraction osteotomy, or a combination of these based on careful preoperative evaluation.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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Alas H, Passias PG, Diebo BG, Brown AE, Pierce KE, Bortz C, Lafage R, Ames CP, Line B, Klineberg EO, Burton DC, Uribe JS, Kim HJ, Daniels AH, Bess S, Protopsaltis T, Mundis GM, Shaffrey CI, Schwab FJ, Smith JS, Lafage V. Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:279-286. [PMID: 34728995 PMCID: PMC8501813 DOI: 10.4103/jcvjs.jcvjs_29_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/07/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), though patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD-corrective surgery with regards to HK and hyperlordosis (HL). Materials and Methods: Operative CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, cervical sagittal vertical axis [cSVA] >4 cm, chin-brow vertical angle >25°) with baseline (BL) and 1Y radiographic data. Patients were stratified based on BL C2-7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (−6.96° ±21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (≤28.43°) depending on directionality. Patients within 1 SD were considered the control group. Results: One hundred and two surgical CD pts (61 years, 65%F, 30 kg/m2) with BL and 1Y radiographic data were included. Twenty pts met definitions for HK and 21 pts met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with the posterior approach. Op-time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-sagittal vertical axis (SVA) (10.8 vs. 7.0 vs. −47.8 mm, P = 0.001). HL pts had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had × 3 revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL pts had higher cSVA, and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK pts had higher McGregor's-slope (16.1° vs. −3.3°, P = 0.001) and C0-C2 Cobb (43.3° vs. 26.9°, P < 0.001), however postoperative differences in McGregor's slope and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary computed tomography (38.1%), upper thoracic (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1Y postoperative, perhaps due to undercorrection compared to kyphotic etiologies.
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Affiliation(s)
- Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Downstate Medical Center, State University of New York, Brooklyn, NY, USA
| | - Avery E Brown
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Cole Bortz
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Juan S Uribe
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Themistocles Protopsaltis
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
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Passias PG, Bortz C, Pierce KE, Kummer NA, Lafage R, Diebo BG, Line BG, Lafage V, Burton DC, Klineberg EO, Kim HJ, Daniels AH, Mundis GM, Protopsaltis TS, Eastlack RK, Sciubba DM, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery. Spine (Phila Pa 1976) 2021; 46:1437-1447. [PMID: 33710114 DOI: 10.1097/brs.0000000000004033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospective cervical deformity (CD) database. OBJECTIVE Identify factors associated with distal junctional kyphosis (DJK); assess differences across DJK types. SUMMARY OF BACKGROUND DATA DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types. METHODS Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences. RESULTS Included: 136 CD patients (61 ± 10 yr, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both P < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (P = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than nonsevere (all P < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all P < 0.03) than static. Each type had varying associated factors. CONCLUSION Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Katherine E Pierce
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Nicholas A Kummer
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Breton G Line
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, CA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | | | | | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shay Bess
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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Passias PG, Pierce KE, Naessig S, Ahmad W, Passfall L, Lafage R, Lafage V, Kim HJ, Daniels A, Eastlack R, Klineberg E, Line B, Mummaneni P, Hart R, Burton D, Bess S, Schwab F, Shaffrey C, Smith JS, Ames CP. At What Point Should the Thoracolumbar Region Be Addressed in Patients Undergoing Corrective Cervical Deformity Surgery? Spine (Phila Pa 1976) 2021; 46:E1113-E1118. [PMID: 34559752 DOI: 10.1097/brs.0000000000004045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the impact of cervical to thoracolumbar ratios on poor outcomes in cervical deformity (CD) corrective surgery. SUMMARY OF BACKGROUND DATA Consideration of distal regional and global alignment is a critical determinant of outcomes in CD surgery. For operative CD patients, it is unknown whether certain thoracolumbar parameters play a significant role in poor outcomes and whether addressing such parameters is warranted. METHODS Included: surgical CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, or chin-brow vertical angle >25°) with baseline and 1-year data. Patients were assessed for ratios of preop cervical and global parameters including: C2 Slope/T1 slope, T1 slope minus C2-C7 lordosis (TS-CL)/mismatch between pelvic incidence and lumbar lordosis (PI-LL), cSVA/sagittal vertical axis (SVA). Deformity classification ratios of cervical (Ames-ISSG) to spinopelvic (SRS-Schwab) were investigated: cSVA modifier/SVA modifier, TS-CL modifier/PI-LL modifier. Cervical to thoracic ratios included C2-C7 lordosis/T4-T12 kyphosis. Correlations assessed the relationship between ratios and poor outcomes (major complication, reoperation, distal junctional kyphosis (DJK), or failure to meet minimal clinically important difference [MCID]). Decision tree analysis through multiple iterations of multivariate regressions assessed cut-offs for ratios for acquiring suboptimal outcomes. RESULTS A total of 110 CD patients were included (61.5 years, 66% F, 28.8 kg/m2). Mean preoperative radiographic ratios calculated: C2 slope/T1 slope of 1.56, TS-CL/PI-LL of 11.1, cSVA/SVA of 5.4, CL/thoracic kyphosis (TK) of 0.26. Ames-ISSG and SRS-Schwab modifier ratios: cSVA/SVA of 0.1 and TS-CL/PI-LL of 0.35. Pearson correlations demonstrated a relationship between major complications and baseline TS-CL/PI-LL, Ames TS-CL/Schwab PI-LL modifiers, and the CL/TK ratios (P < 0.050). Reoperation had significant correlation with TS-CL/PI-LL and cSVA/SVA ratios. Postoperative DJK correlated with C2 slope/T1 slope and CL/TK ratios. Not meeting MCID for Neck Disability Index (NDI) correlated with CL/TK ratio and not meeting MCID for EQ5D correlated with Ames TS-CL/Schwab PI-LL. CONCLUSION Consideration of cervical to global alignment is a critical determinant of outcomes in CD corrective surgery. Key ratios of cervical to global alignment correlate with suboptimal clinical outcomes. A larger cervical lordosis to TK predicted postoperative complication, DJK, and not meeting MCID for NDI.Level of Evidence: 4.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Sara Naessig
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Waleed Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Praveen Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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Kim CW, Hyun SJ, Kim KJ. Systematic Review of Reciprocal Changes after Spinal Reconstruction Surgery : Do Not Miss the Forest for the Trees. J Korean Neurosurg Soc 2021; 64:843-852. [PMID: 34619822 PMCID: PMC8590906 DOI: 10.3340/jkns.2020.0234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
The purpose of this review was to synthesize the research on global spinal alignment and reciprocal changes following cervical or thoracolumbar reconstruction surgery. We carried out a search of PubMed, EMBASE, and Cochrane Library for studies through May 2020, and ultimately included 11 articles. The optimal goal of a truly balanced spine is to maintain the head over the femoral heads. When spinal imbalance occurs, the human body reacts through various compensatory mechanisms to maintain the head over the pelvis and to retain a horizontal gaze. Historically, deformity correction has focused on correcting scoliosis and preventing scoliotic curve progression. Following substantial correction of a spinal deformity, reciprocal changes take place in the flexible segments proximal and distal to the area of correction. Restoration of lumbar lordosis following surgery to correct a thoracolumbar deformity induces reciprocal changes in T1 slope, cervical lordosis, pelvic shift, and lower extremity parameters. Patients with cervical kyphosis exhibit different patterns of reciprocal changes depending on whether they have head-balanced or trunk-balanced kyphosis. These reciprocal changes should be considered to in order to prevent secondary spine disorders. We emphasize the importance of evaluating the global spinal alignment to assess postoperative changes.
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Affiliation(s)
- Chang-Wook Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Martini ML, Neifert SN, Chapman EK, Mroz TE, Rasouli JJ. Cervical Spine Alignment in the Sagittal Axis: A Review of the Best Validated Measures in Clinical Practice. Global Spine J 2021; 11:1307-1312. [PMID: 33203239 PMCID: PMC8453677 DOI: 10.1177/2192568220972076] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
STUDY DESIGN Review of the best-validated measures of cervical spine alignment in the sagittal axis. OBJECTIVE Describe the C2-C7 Cobb Angle, C2-C7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus C2-C7 lordosis, C2 slope, and different types of cervical kyphosis. METHODS Search PubMed for recent technical literature on radiograph-based measurements of the cervical spine. RESULTS Despite the continuing use of measures developed many years ago such as the C2-C7 Cobb angle, there are new radiographic parameters being published and utilized in recent years, including the C2 slope. Further research is needed to compare older and newer measures for cross-validation. Utilizing these measures to determine the degree of correction intraoperatively and postoperatively will enable surgeons to optimize patient-level outcomes. CONCLUSION Cervical spinal deformity can be a debilitating condition characterized by cervical spinal misalignment that affects the elderly more commonly than young populations. Many of these validated measures of cervical spinal alignment are useful in clinical settings due to their ease of implementation and correlations with various postoperative and health-related quality of life outcomes.
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Affiliation(s)
- Michael L. Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Michael L. Martini, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K. Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA
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Tao Y, Niemeyer F, Galbusera F, Jonas R, Samartzis D, Vogele D, Kienle A, Wilke HJ. Sagittal wedging of intervertebral discs and vertebral bodies in the cervical spine and their associations with age, sex and cervical lordosis: A large-scale morphological study. Clin Anat 2021; 34:1111-1120. [PMID: 34309067 DOI: 10.1002/ca.23769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 11/11/2022]
Abstract
Many recent studies have focused on the functional and clinical importance of cervical lordosis. However, there is little accurate knowledge of the anatomical parameters that constitute cervical lordosis (i.e., the sagittal wedging angles of intervertebral discs and vertebral bodies) and their associations with age and sex. Standing lateral cervical radiographs of 1020 subjects (424 males, 596 females) with a mean age of 36.6 ± 17.0 years (range 7-95 years) were evaluated retrospectively. Cervical lordosis, the sum of intervertebral disc wedging angles from C2/C3 to C6/C7 and the sum of vertebral body wedging angles from C3 to C7 were measured. The sum of intervertebral disc wedging and the sum of vertebral body wedging were 20.6° ± 14.7° and -12.8° ± 10.3°, respectively. The sum of intervertebral disc wedging increased significantly with age and was significantly greater in males than females, whereas there was no sex-related difference in the sum of vertebral body wedging. The sum of intervertebral disc wedging was negatively correlated with sum of vertebral body wedging. Wedging of discs contributed to C2-C7 cervical lordosis more significantly than wedging of vertebral bodies. There were moderate positive correlations between cervical lordosis and intervertebral disc wedging angles at C3/C4, C4/C5 and C5/C6; weak correlations were observed at C2/C3 and C6/C7. This study constitutes the largest currently available analysis comprehensively documenting the anatomical characteristics of sagittal wedging of intervertebral discs and vertebral bodies in the cervical spine. The findings could improve understanding of the internal architecture of cervical lordosis among clinicians.
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Affiliation(s)
- Youping Tao
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University Medical Centre, Ulm, Germany
| | - Frank Niemeyer
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University Medical Centre, Ulm, Germany
| | | | - René Jonas
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University Medical Centre, Ulm, Germany
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center and Rush Graduate College, Chicago, Illinois, USA.,International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, Illinois, USA
| | - Daniel Vogele
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | | | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University Medical Centre, Ulm, Germany
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Tao Y, Galbusera F, Niemeyer F, Jonas R, Samartzis D, Vogele D, Wilke HJ. The impact of age, sex, disc height loss and T1 slope on the upper and lower cervical lordosis: a large-scale radiologic study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2434-2442. [PMID: 34331122 DOI: 10.1007/s00586-021-06933-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/14/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To clarify the relative influence of age, sex, disc height loss and T1 slope on upper (Occiput-C2) and lower cervical lordosis (C2-C7). METHODS Standing lateral cervical radiographs of 865 adult subjects were evaluated. The presence and severity of disc height loss from C2/C3 to C6/C7 (a total of 4325 discs) were assessed using a validated grading system. The total disc height loss score for each subject was calculated as the sum of the score of each disc space. Sagittal radiographic parameters included: occipital slope, occiput-C2 (Oc-C2) lordosis, C2-C7 lordosis and T1 slope. Multivariable regression analyses were performed to examine the relative influence of the multiple factors on upper and lower cervical lordosis. RESULTS This study included 360 males and 505 females, with a mean age of 40.2 ± 16.0 years (range, 20-95 years). Linear multivariate regression analyses showed that greater age, male sex, greater T1 slope were each found to be significantly and independently associated with greater C2-C7 lordosis, whereas total disc height loss score was negatively associated with C2-C7 lordosis. T1 slope had the most independent influence on C2-C7 lordosis among these factors. Age, sex and disc height loss were not independently associated with Oc-C2 lordosis. CONCLUSIONS Results from our large-scale radiologic analysis may enhance the understanding of the factors that affect cervical lordosis, indicating that age, sex, disc height loss and T1 slope were each independently associated with C2-C7 lordosis. However, age, sex and disc height loss were not independently associated with upper cervical lordosis.
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Affiliation(s)
- Youping Tao
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | | | - Frank Niemeyer
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | - René Jonas
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center and Rush Graduate College, Chicago, IL, USA.,International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL, USA
| | - Daniel Vogele
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany.
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Suzuki A, Ishii K, Igawa T, Isogai N, Ui H, Urata R, Ideura K, Sasao Y, Funao H. Effect of the short and intensive rehabilitation (SHAiR) program on dynamic alignment in patients with dropped head syndrome during level walking. J Clin Neurosci 2021; 91:93-98. [PMID: 34373067 DOI: 10.1016/j.jocn.2021.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/07/2021] [Accepted: 06/12/2021] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to assess the change of dynamic alignment after the short and intensive rehabilitation (SHAiR) program in patients with dropped head syndrome (DHS). Eighteen patients with DHS patients who complained of their inability to maintain horizontal gaze and underwent the SHAiR program. Patients performed level walking at a self-selected speed. Spatiotemporal, kinematic, and kinetic data were recorded using a three-dimensional motion analysis system. Statistical analysis was performed to compare these data before and after the SHAiR program. Those who underwent the SHAiR program showed a significant increase in the head angle and stride length compared to pre-treatment measurements (p < 0.05). The SHAiR program modifies the malalignment of the head and neck and spatiotemporal parameters in DHS patients during level walking.
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Affiliation(s)
- Akifumi Suzuki
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan.
| | - Tatsuya Igawa
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Physical Therapy, School of Health Science, International University of Health and Welfare, 2600-1, Kitakanemaru, Ohtawara, Tochigi 323-8501, Japan
| | - Norihiro Isogai
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Hideto Ui
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Ryunosuke Urata
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Kentaro Ideura
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Yutaka Sasao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita City, Chiba 286-8520, Japan; Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo 108-8329, Japan.
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Yang SH, Kim CH, Lee CH, Ko YS, Won Y, Chung CK. C7 Fracture as a Complication of C7 Dome-Like Laminectomy : Impact on Clinical and Radiological Outcomes and Evaluation of the Risk Factors. J Korean Neurosurg Soc 2021; 64:575-584. [PMID: 34185984 PMCID: PMC8273780 DOI: 10.3340/jkns.2021.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Cervical expansive laminoplasty is an effective surgical method to address multilevel cervical spinal stenosis. During surgery, the spinous processes of C2 and C7 are usually preserved to keep the insertion points of the cervical musculature and nuchal ligament intact. In this regard, dome-like laminectomy (undercutting of C7 lamina) instead of laminoplasty is performed on C7 in selected cases. However, resection of the lamina can weaken the C7 lamina, and stress fractures may occur, but this complication has not been characterized in the literature. The objective of the present study was to investigate the incidence and risk factors for C7 laminar fracture after C7 dome-like laminectomy and its impact on clinical and radiological outcomes.
Methods Patients who underwent cervical open-door laminoplasty combined with C7 dome-like laminectomy (n=123) were classified according to the presence of C7 laminar fracture. Clinical parameters (neck/arm pain score and neck disability index) and radiologic parameters (C2–7 angle, C2–7 sagittal vertical axis, and C7–T1 angle) were compared between the groups preoperatively and at postoperatively at 3, 6, 12, and 24 months. Risk factors for complications were evaluated, and a formula estimating C7 fracture risk was suggested.
Results C7 lamina fracture occurred in 32/123 (26%) patients and occurred at the bilateral isthmus in 29 patients and at the spinolaminar junction in three patients. All fractures appeared on X-ray within 3 months postoperatively, but patients did not present any neurological deterioration. The fracture spontaneously healed in 27/32 (84%) patients at 1 year and in 29/32 (91%) at 2 years. During follow-up, clinical outcomes were not significantly different between the groups. However, patients with C7 fractures showed a more lordotic C2–7 angle and kyphotic C7–T1 angle than patients without C7 fractures. C7 fracture was significantly associated with the extent of bone removal. By incorporating significant factors, the probability of C7 laminar fracture could be assessed with the formula 'Risk score = 1.08 × depth (%) + 1.03 × length (%, of the posterior height of C7 vertebral body)', and a cut-off value of 167.9% demonstrated a sensitivity of 90.3% and a specificity of 65.1% (area under the curve, 0.81).
Conclusion C7 laminar fracture can occur after C7 dome-like laminectomy when a substantial amount of lamina is resected. Although C7 fractures may not cause deleterious clinical outcomes, they can lead to an unharmonized cervical curvature. The chance of C7 fracture should be discussed in the shared decision-making process.
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Affiliation(s)
- Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyun Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young San Ko
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Youngil Won
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
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Passias PG, Pierce KE, Brown AE, Bortz CA, Alas H, Lafage R, Lafage V, Line B, Klineberg EO, Burton DC, Hart R, Daniels AH, Bess S, Diebo B, Protopsaltis T, Eastlack R, Shaffrey CI, Schwab FJ, Smith JS, Ames C, On Behalf Of The International Spine Study Group. Redefining cervical spine deformity classification through novel cutoffs: An assessment of the relationship between radiographic parameters and functional neurological outcomes. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:157-164. [PMID: 34194162 PMCID: PMC8214235 DOI: 10.4103/jcvjs.jcvjs_22_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Avery E Brown
- Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY, USA
| | | | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, USA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Fujishiro T, Hayama S, Obo T, Nakaya Y, Nakano A, Usami Y, Nozawa S, Baba I, Neo M. Gap between flexion and extension ranges of motion: a novel indicator to predict the loss of cervical lordosis after laminoplasty in patients with cervical spondylotic myelopathy. J Neurosurg Spine 2021; 35:8-17. [PMID: 33930862 DOI: 10.3171/2020.10.spine201723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Kyphotic deformity resulting from the loss of cervical lordosis (CL) is a rare but serious complication after cervical laminoplasty (CLP), and it is essential to recognize the risk factors. Previous studies have demonstrated that a greater flexion range of motion (fROM) and smaller extension ROM (eROM) in the cervical spine are associated with the loss of CL after CLP. Considering these facts together, one can hypothesize that an indicator representing the gap between fROM and eROM (gROM) is highly useful in predicting postoperative CL loss. In the present study, the authors aimed to investigate the risk factors of marked CL loss after CLP for cervical spondylotic myelopathy (CSM), including the gROM as a potential predictor. METHODS Patients who had undergone CLP for CSM were divided into those with and those without a loss of more than 10° in the sagittal Cobb angle between C2 and C7 at the final follow-up period compared to preoperative measurements (CL loss [CLL] group and no CLL [NCLL] group, respectively). Demographic characteristics, surgical information, preoperative radiographic measurements, and posterior paraspinal muscle morphology evaluated with MRI were compared between the two groups. fROM and eROM were examined on neutral and flexion-extension views of lateral radiography, and gROM was calculated using the following formula: gROM (°) = fROM - eROM. The performance of variables in discriminating between the CLL and NCLL groups was assessed using the receiver operating characteristic (ROC) curve. RESULTS This study included 111 patients (mean age at surgery 68.3 years, 61.3% male), with 10 and 101 patients in the CLL and NCLL groups, respectively. Univariate analyses showed that fROM and gROM were significantly greater in the CLL group than in the NCLL group (40.2° vs 26.6°, p < 0.001; 31.6° vs 14.3°, p < 0.001, respectively). ROC curve analyses revealed that both fROM and gROM had excellent discriminating capacities; gROM was likely to have a higher area under the ROC curve than fROM (0.906 vs 0.860, p = 0.094), with an optimal cutoff value of 27°. CONCLUSIONS The gROM is a highly useful indicator for predicting a marked loss of CL after CLP. For CSM patients with a preoperative gROM exceeding 30°, CLP should be carefully considered, since kyphotic changes can develop postoperatively.
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Affiliation(s)
- Takashi Fujishiro
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
- 2Department of Orthopedic Surgery, First Towakai Hospital, Takatsuki, Osaka, Japan
| | - Sachio Hayama
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Takuya Obo
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
- 2Department of Orthopedic Surgery, First Towakai Hospital, Takatsuki, Osaka, Japan
| | - Yoshiharu Nakaya
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Atsushi Nakano
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Yoshitada Usami
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Satoshi Nozawa
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Ichiro Baba
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
| | - Masashi Neo
- 1Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
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Sagittal balance of the cervical spine: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1411-1439. [PMID: 33772659 DOI: 10.1007/s00586-021-06825-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 09/26/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to compare the cervical sagittal parameters between patients with cervical spine disorder and asymptomatic controls. METHODS Two independent authors systematically searched online databases including Pubmed, Scopus, Cochrane library, and Web of Science up to June 2020. Cervical sagittal balance parameters, such as T1 slope, cervical SVA (cSVA), and spine cranial angle (SCA), were compared between the cervical spine in healthy, symptomatic, and pre-operative participants. Where possible, we pooled data using random-effects meta-analysis, by CMA software. Heterogeneity and publication bias were assessed using the I-squared statistic and funnel plots, respectively. RESULTS A total of 102 studies, comprising 13,802 cases (52.7% female), were included in this meta-analysis. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Funnel plot and Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the mean (SD) values were: T1 slope (degree), 24.5 (0.98), 25.7 (0.99), 25.4 (0.34); cSVA (mm), 18.7 (1.76), 22.7 (0.66), 22.4 (0.68) for healthy population, symptomatic, and pre-operative assessment, respectively. The mean value of the SCA (degree) was 79.5 (3.55) and 75.6 (10.3) for healthy and symptomatic groups, respectively. Statistical differences were observed between the groups (all P values < 0.001). CONCLUSION The findings showed that the T1 slope and the cSVA were significantly lower among patients with cervical spine disorder compared to controls and higher for the SCA. Further well-conducted studies are needed to complement our findings.
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Long-term Radiographic Outcome of Occipitocervical Fixation: An Analysis of Fusion Rate and Spontaneous Subaxial Alignment Change at an Average 7-year Follow-up. Spine (Phila Pa 1976) 2021; 46:152-159. [PMID: 33065696 DOI: 10.1097/brs.0000000000003757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to investigate the long-term radiographic outcome of patients who underwent occipitocervical fixation (OCF) using a modern screw/rod system. SUMMARY OF BACKGROUND DATA Few studies have reported fusion rates and radiographic alignment changes in unfused subaxial segments after OCF at a long-term follow-up. METHODS We retrospectively reviewed 22 patients who underwent OCF with a modern screw-based construct. The patients satisfied the minimum 2-year radiographic follow-up. Baseline demographics and the following pre- and postoperative sagittal alignment parameters were investigated. McGregor slope, O-C2 angle (OC2A), and C2-7 Cobb angle (CL). We grouped patients into those whose OC2A increased postoperatively (OC2A-increase group) and those whose OC2A decreased postoperatively (OC2A-decrease group). The postoperative sagittal alignment change was compared between the 2 groups at the final follow-up. The perioperative complications as well as fusion status based on computed tomography (CT) were investigated. RESULTS The average follow-up period was 89.7 months. The lowest instrumented vertebra was at C2 (63.6%), C3 (18.1%), or C4 (18.1%). The fusion rate at the final follow-up was 77.2%. Postoperative dysphasia occurred in two patients (16.6%) in the OC2A-decrease group, whereas distal junctional kyphosis was observed in two patients (20.0%) in the OC2A-increase group. The OC2A-increase group demonstrated a mean 4.8° decrease in CL as a compensation for the 5.1° increase in OC2A. In contrast, the OC2A-decrease group showed a mean 9.2° increase in CL as a compensation for the 6.3° decrease in OC2A. CONCLUSION The CT-confirmed fusion rate of OCF was 77.2% over an average 89.7-month follow-up. Compensatory sagittal alignment change can occur in the unfused subaxial segments in conjunction with the alignment change in the instrumented OC segments, whereas the horizontal gaze was maintained. Strong consideration for the intraoperative measurement of the OC2A should be given during OCF to minimize both early and long-term complications.Level of Evidence: 4.
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Sivaganesan A, Smith JS, Kim HJ. Cervical Deformity: Evaluation, Classification, and Surgical Planning. Neurospine 2020; 17:833-842. [PMID: 33401860 PMCID: PMC7788408 DOI: 10.14245/ns.2040524.262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
Cervical deformity is a challenging condition to treat and requires complex decision-making. Apart from a thorough history and physical examination, a thoughtful and quantitative analysis of multiple imaging modalities is critical for understanding the nature and driver of the cervical deformity. A few classification schemes have emerged, and it is now clear that dynamic films are invaluable as they capture the extension reserve that patients can use to compensate for malalignment. These classification systems can help guide surgical planning, because the various subgroups have different properties that lend themselves to specific treatment paradigms. Here we review the clinical and radiographic evaluation, classification, and surgical planning for cervical deformity.
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Affiliation(s)
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
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Virk S, Lafage R, Elysee J, Louie P, Kim HJ, Albert T, Lenke LG, Schwab F, Lafage V. The 3 Sagittal Morphotypes That Define the Normal Cervical Spine: A Systematic Review of the Literature and an Analysis of Asymptomatic Volunteers. J Bone Joint Surg Am 2020; 102:e109. [PMID: 33027127 DOI: 10.2106/jbjs.19.01384] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical alignment is vital for maintaining horizontal gaze and sagittal balance. The aims of this study were to summarize previously published descriptions of normative cervical alignment and to analyze a cohort of asymptomatic volunteers in order to identify natural clusters of normal radiographic parameters. METHODS We performed a systematic review of the literature on radiographic measurements of asymptomatic volunteers through a search of MEDLINE and ScienceDirect databases. We then performed an analysis of demographic and radiographic parameters of volunteers without back or neck complaints. Only subjects with a chin-brow vertical angle (CBVA) within previously published normal limits were retained for analysis. A 2-step cluster analysis was used to find natural groups of cervical alignment. Differences among groups were investigated with a post hoc analysis of variance (ANOVA). RESULTS We included 37 articles in our analysis. There was a broad spectrum of both C2-C7 lordosis-kyphosis and T1 slope across ages and sexes. Of the 119 asymptomatic volunteers who were available for analysis, 84 (with a mean age [and standard deviation] of 49.0 ± 17.1 years) had a CBVA ranging from -4.7° to 17.7°. The cluster analysis identified 3 alignment groups based on cervical lordosis-kyphosis and T1 slope (silhouette measure of cohesion, >0.6). Twenty-seven volunteers (32.1%) were identified as the "kyphotic curve cohort" (KCC) (mean C2-C7 Cobb angle, -8.6° ± 7.3°; mean T1 slope, 17.4° ± 6.6°), 43 volunteers (51.2%) were identified as the "medium lordosis cohort" (MLC) (mean C2-C7 Cobb angle, 8.7° ± 7.2°; mean T1 slope, 26.6° ± 4.0°), and 14 volunteers (16.7%) were identified as the "large lordosis cohort" (LLC) (mean C2-C7 Cobb angle, 21.2° ± 7.2°, mean T1 slope, 39.5° ± 6.4°) (p < 0.001 for both). Moving from KCC to LLC, there was a significant decrease in C0-C2 lordosis (p = 0.016). Examination of the cervical vertebral orientation demonstrated that C4 had a constant orientation relative to the horizontal (p = 0.665). Correlation analysis between C2-C7 and vertebral orientations again demonstrated that C4 orientation was independent of C2-C7 alignment. CONCLUSIONS We have identified 3 morphotypes of the cervical spine based on C2-C7 alignment and T1 slope. These findings demonstrate the broad definition of normal cervical alignment and the range of cervical lordosis-kyphosis that is acceptable.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Jonathan Elysee
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Philip Louie
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Todd Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
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Abstract
STUDY DESIGN A mechanism-based reasoning and case-control study. OBJECTIVE To introduce correction target of clivo-axial angle (CXA) in quantitative surgical reduction of basilar invagination (BI). SUMMARY OF BACKGROUND DATA The exact mechanism of BI with or without atlantoaxial dislocation is still unclear. Sagittal deformity is a key feature of BI. Correction of CXA directly influences subaxial cervical lordosis (increase of CXA equals the decrease of cervical lordosis). However, a quantitative reference for correction surgery has not been established. MATERIALS AND METHODS CXA was divided by Chamberlain line into clivus tilt (CT) and axial tilt (AT). Patients diagnosed with BI were retrospectively included. Patients with degenerative cervical spine diseases or vascular diseases (without BI) were included as controls. CT, AT, and other common parameters were measured and analyzed with t test and multiple linear regression. Demonstration case was presented. RESULTS A total of 42 BI patients and 23 controls were included. Normal references for CXA, AT, and CT were 162.3±7.1, 93.8±6.5, and 68.6±3.8 degrees, respectively. BI patients had a 30.3-degree smaller CXA, a 15.5-degree smaller AT, and a 14.9-degree smaller CT. Basal angle (P=0.002) independently had a significant influence on extent of BI, while CT and AT did not. Demonstration case showed that CT was fixed and correcting AT to an ideal 94 degrees was optimal for an individual patient. CONCLUSIONS Proper quantitative correction of CXA needs to be individualized in consideration of CT and AT. The difference between actual AT and its ideal value (about 94 degrees) is the optimal target of CXA correction to decompress neural elements ventrally and recover better subaxial cervical lordosis. LEVEL OF EVIDENCE Level IV.
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Hasegawa K, Okamoto M, Hatsushikano S, Watanabe K, Ohashi M, Vital JM, Dubousset J. Compensation for standing posture by whole-body sagittal alignment in relation to health-related quality of life. Bone Joint J 2020; 102-B:1359-1367. [DOI: 10.1302/0301-620x.102b10.bjj-2019-1581.r2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL). Methods A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups. Results On the basis of cluster analysis of the SRS-22r subscores, the pooled subjects were divided into three HRQOL groups as follows: almost normal (mean 4.24 (SD 0.32)), mildly disabled (mean 3.32 (SD 0.24)), and severely disabled (mean 2.31 (SD 0.35)). Except for CAM-GL, all the alignment parameters differed significantly among the cluster groups. The threshold values of key alignment parameters for severe disability were TPA > 30°, C2-7 lordosis > 13°, PI-LL > 30°, PT > 28°, and knee flexion > 8°. Lumbar spinal stenosis was found to be associated with the symptom severity. Conclusion This study provides evidence that the three grades of sagittal compensation in whole body alignment correlate with HRQOL scores. The compensation grades depend on the clinical diagnosis, whole body sagittal alignment, and lumbar spinal stenosis. The threshold values of key alignment parameters may be an indication for treatment. Cite this article: Bone Joint J 2020;102-B(10):1359–1367.
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Affiliation(s)
| | | | | | - Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University Hospital, Niigata, Japan
| | - Masayuki Ohashi
- Department of Orthopaedic Surgery, Niigata University Hospital, Niigata, Japan
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Mandibular slope: a reproducible and simple measure of horizontal gaze. Spine Deform 2020; 8:893-899. [PMID: 32495207 DOI: 10.1007/s43390-020-00137-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN This study is a single-center retrospective radiographic review. OBJECTIVES The objective of this study is to evaluate a novel measurement parameter, mandibular slope (MS), as a measure of horizontal gaze. INTRODUCTION Assessment of sagittal spinal alignment is essential in the evaluation of spinal deformity patients. Ability to achieve a horizontal gaze, a parameter of sagittal alignment, is needed for the performance of daily activities. Standard measures of horizontal gaze, including the gold-standard chin-brow to vertical angle (CBVA) and the surrogate measures McGregor's line (McGS) and Chamberlain's line (CS), require high-quality imaging, precise head positioning, and reliance on difficult to view visual landmarks. A novel measurement parameter, MS, utilizing the caudal margin of the mandible on standard lateral spine radiographs is proposed. METHODS 90 radiographs from spine deformity patients with or without spinal implants from a single center were evaluated. Three spine surgery fellows independently measured CBVA, McGS, CS, and MS at two timepoints at least one week apart to assess accuracy and reliability. MS was measured as the angle created by the inferior edge of the mandibular body and the horizontal. Formulas for calculating CBVA based on the above parameters were derived and compared to the actual CBVA. RESULTS Mean age was 49.7 years, 76 females and 14 males. CBVA correlated with CS, McGS, and MS, r = 0.85, 0.81, and 0.80, respectively (p < 0.001). Standard error between real CBVA and calculated CBVA using CS (0.4 ± 4.79) and McGS (0.4 ± 3.9) was higher than that calculated using MS (- 0.2 ± 4.3). ICC demonstrated the highest inter-observer reliability with MS (0.999). MS had the highest intra-observer reliabilities 0.975, 0.981, and 0.988 (p < 0.001); CS and McGS also demonstrated high intra-observer reliability. CONCLUSIONS MS is a promising measure of horizontal gaze that correlates highly with CBVA, has excellent intra- and inter-observer reliability with CBVA, and is easily measured using standard lateral spine radiographs.
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Kim CW, Hyun SJ, Kim KJ. Surgical Impact on Global Sagittal Alignment and Health-Related Quality of Life Following Cervical Kyphosis Correction Surgery: Systematic Review. Neurospine 2020; 17:497-504. [PMID: 33022154 PMCID: PMC7538364 DOI: 10.14245/ns.2040476.238] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
When spinal imbalance occurs, the human body reacts through various compensatory mechanisms to maintain the head over the pelvis and to retain a horizontal gaze. These compensations occur through mobile spine segments as well as pelvic tilt and lower extremities. The purpose of this review was to understand the surgical impact on global sagittal alignment and health-related quality of life (HRQoL) following cervical kyphosis correction surgery. The cervical kyphosis correction surgery induces reciprocal changes in craniocervical and thoracolumbar alignment. Successful cervical deformity correction needs to focus not only on restoring proper cervical lordosis, but also on achieving global balance of the cervical spine with other parts of the spine. The goal of the surgery is to achieve occiputtrunk (OT) concordance (the center of gravity-C7 sagittal vertical axis < 30 mm) and cervical sagittal balance. Once OT-concordance is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize global spinal alignment. Reciprocal changes after surgery exhibit different patterns depending on whether patients have compensation ability in their thoracolumbar spine or not. C2–7 sagittal vertical axis and sagittal morphotype of the cervical kyphosis are correlated with HRQoL. Changes in cervical lordosis minus T1 slope correlate to HRQoL improvements.
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Affiliation(s)
- Chang-Wook Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Lee SH, Hyun SJ, Jain A. Cervical Sagittal Alignment: Literature Review and Future Directions. Neurospine 2020; 17:478-496. [PMID: 33022153 PMCID: PMC7538362 DOI: 10.14245/ns.2040392.196] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022] Open
Abstract
Cervical alignment as a concept has come to the forefront for spine deformity research in the last decade. Studies on cervical sagittal alignment started from normative data, and expanded into correlation with global sagittal balance, prognosis of various conditions, outcomes of surgery, definition and classification of cervical deformity, and prediction of targets for ideal cervical reconstruction. Despite the recent robust research efforts, the definition of normal cervical sagittal alignment and cervical spine deformity continues to elude us. Further, many studies continue to view cervical alignment as a continuation of thoracolumbar deformity and do not take into account biomechanical features unique to the cervical spine that may influence cervical alignment, such as the importance of musculature connecting cranium-cervical-thoracic spine and upper extremities. In this article, we aim to summarize the relevant literature on cervical sagittal alignment, discuss key results, and list potential future direction for research using the '5W1H' framework; "WHO" are related?, "WHY" important?, "WHAT" to evaluate and "WHAT" is normal?, "HOW" to evaluate?, "WHEN" to apply sagittal balance?, and "WHERE" to go in the future?
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Affiliation(s)
- Sang Hun Lee
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Seung-Jae Hyun
- Department of Neurological Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Bortz C, Passias PG, Pierce KE, Alas H, Brown A, Naessig S, Ahmad W, Lafage R, Ames CP, Diebo BG, Line BG, Klineberg EO, Burton DC, Eastlack RK, Kim HJ, Sciubba DM, Soroceanu A, Bess S, Shaffrey CI, Schwab FJ, Smith JS, Lafage V. Radiographic benefit of incorporating the inflection between the cervical and thoracic curves in fusion constructs for surgical cervical deformity patients. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:131-138. [PMID: 32905029 PMCID: PMC7462144 DOI: 10.4103/jcvjs.jcvjs_57_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose: The aim is to assess the relationship between cervicothoracic inflection point and baseline disability, as well as the relationship between clinical outcomes and pre- to postoperative changes in inflection point. Methods: Cervical deformity (CD) patients with baseline and 3-month (3M) postoperative radiographic, clinical, and inflection data were grouped by region of inflection point: C6 or above, C6-C7 to C7-T1, T1, or below. Inflection was defined as: Distal-most level where cervical lordosis (CL) changes to thoracic kyphosis (TK). Differences in alignment and patient factors across pre- and postoperative inflection point groups were assessed, as were outcomes by the inclusion of inflection in the CD-corrective fusion construct. Results: A total of 108 patients were included. Preoperative inflection breakdown: C6 or above (42%), C6-C7 to C7-T1 (44%), T1 or below (15%). Surgery was associated with a caudal migration of inflection by 3M: C6 or above (8%), C6-C7 to C7-T1 (58%), T1 or below (33%). For patients with preoperative inflection T1 or below, the inclusion of inflection in the fusion construct was associated with improvements in horizontal gaze (McGregor's Slope included: −11.3° vs. not included: 1.6°, P = 0.038). The inclusion of preoperative inflection in fusion was associated with the superior cervical sagittal vertical axis (cSVA) changes for C6-C7 to C7-T1 patients (−5.2 mm vs. 3.2 mm, P = 0.018). The location of postoperative inflection was associated with variation in 3M alignment: Inflection C6 or above was associated with less Pelvic Tilt (PT), PT and a trend of larger cSVA. Location of inflection or inclusion in fusion was not associated with reoperation or distal junctional kyphosis. Conclusions: Incorporating the inflection point between CL and TK in the fusion construct was associated with superior restoration of cervical alignment and horizontal gaze for surgical CD patients.
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Affiliation(s)
- Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | | | - Haddy Alas
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | - Avery Brown
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | - Sara Naessig
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | - Waleed Ahmad
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, CA, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery New York, NY, USA
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Haddas R, Kisinde S, Mar D, Lieberman I. Does improved radiographic alignment truly enhance dynamic functional balance? Spine Deform 2020; 8:685-694. [PMID: 32065379 DOI: 10.1007/s43390-020-00089-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Prospective concurrent cohort study. OBJECTIVE To establish the relationship between radiographic alignment parameters and functional CoE measurements at 1 week before and at 3 months after realignment surgery in ADS patients. Adult degenerative scoliosis (ADS) represents a significant healthcare burden with exceedingly high and increasing prevalence, particularly among the elderly. Radiographic alignment measures and patient-reported outcomes currently serve as the standard means to assess spinal alignment, deformity, and stability. Neurological examinations have served as qualitative measures for indicating muscle strength, motor deficits, and gait abnormalities. Three-dimensional motion analysis is increasingly being used to identify and measure gait and balance instability. Recently, techniques have been established to quantify balance characteristics described by Dubousset as the "cone of economy" (CoE). The relationship between radiographic alignment parameters and CoE balance measures of ADS patients before and after realignment surgery is currently unknown. PATIENT SAMPLE 29 ADS patients treated with realignment surgery. METHODS Patients were evaluated at 1 week before realignment surgery and at their 3-month follow-up examination. During each evaluation, patients completed self-reported outcomes (visual analog scales for pain, Oswestry Disability Index, SRS22r) and a functional balance test. Mean changes in dependent measures from before to after surgery were compared using paired t tests. Pearson correlations were used to test for significant correlations between changes in radiographic and CoE measures. RESULTS Significant improvements were found for all patient-reported outcomes, in several radiographic measures, and in CoE measures. Improvements of scoliosis Cobb angle, coronal pelvic tilt, lumbar lordosis, and thoracic kyphosis showed significant correlations with CoE sway and total distance measures at both the center of mass and center of the head. CONCLUSION Improved radiographic alignment measures significantly correlated with improved CoE balance measures among ADS patients treated with realignment surgery at their three-month follow-up. These findings indicate that functional balance evaluations when used in conjunction with radiographic measurements, may provide a more robust and improved patient-specific sensitivity for postoperative assessments. CoE balance may represent a new measure of added value for surgical intervention of ADS.
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Affiliation(s)
- Ram Haddas
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA.
| | - Stanley Kisinde
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA
| | - Damon Mar
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA
| | - Isador Lieberman
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA
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Defining an Algorithm of Treatment for Severe Cervical Deformity Using Surgeon Survey and Treatment Patterns. World Neurosurg 2020; 139:e541-e547. [DOI: 10.1016/j.wneu.2020.04.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/08/2020] [Indexed: 11/21/2022]
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Lee DH, Lee CS, Hwang CJ, Cho JH, Park JW, Park KB. Improvement in cervical lordosis and sagittal alignment after vertebral body sliding osteotomy in patients with cervical spondylotic myelopathy and kyphosis. J Neurosurg Spine 2020; 33:307-315. [PMID: 32442972 DOI: 10.3171/2020.3.spine2089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vertebral body sliding osteotomy (VBSO) is a safe, novel technique for anterior decompression in patients with multilevel cervical spondylotic myelopathy. Another advantage of VBSO may be the restoration of cervical lordosis through multilevel anterior cervical discectomy and fusion (ACDF) above and below the osteotomy level. This study aimed to evaluate the improvement and maintenance of cervical lordosis and sagittal alignment after VBSO. METHODS A total of 65 patients were included; 34 patients had undergone VBSO, and 31 had undergone anterior cervical corpectomy and fusion (ACCF). Preoperative, postoperative, and final follow-up radiographs were used to evaluate the improvements in cervical lordosis and sagittal alignment after VBSO. C0-2 lordosis, C2-7 lordosis, segmental lordosis, C2-7 sagittal vertical axis (SVA), T1 slope, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and Japanese Orthopaedic Association scores were measured. Subgroup analysis was performed between 15 patients with 1-level VBSO and 19 patients with 2-level VBSO. Patients with 1-level VBSO were compared to patients who had undergone 1-level ACCF. RESULTS C0-2 lordosis (41.3° ± 7.1°), C2-7 lordosis (7.1° ± 12.8°), segmental lordosis (3.1° ± 9.2°), and C2-7 SVA (21.5 ± 11.7 mm) showed significant improvements at the final follow-up (39.3° ± 7.2°, 13° ± 9.9°, 15.2° ± 8.5°, and 18.4 ± 7.9 mm, respectively) after VBSO (p = 0.049, p < 0.001, p < 0.001, and p = 0.038, respectively). The postoperative segmental lordosis was significantly larger in 2-level VBSO (18.8° ± 11.6°) than 1-level VBSO (10.3° ± 5.5°, p = 0.014). The final segmental lordosis was larger in the 1-level VBSO (12.5° ± 6.2°) than the 1-level ACCF (7.2° ± 7.6°, p = 0.023). Segmental lordosis increased postoperatively (p < 0.001) and was maintained until the final follow-up (p = 0.062) after VBSO. However, the postoperatively improved segmental lordosis (p < 0.001) decreased at the final follow-up (p = 0.045) after ACCF. CONCLUSIONS Not only C2-7 lordosis and segmental lordosis, but also C0-2 lordosis and C2-7 SVA improved at the final follow-up after VBSO. VBSO improves segmental cervical lordosis markedly through multiple ACDFs above and below the VBSO level, and a preserved vertebral body may provide more structural support.
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Affiliation(s)
- Dong-Ho Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and
| | - Choon Sung Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and
| | - Chang Ju Hwang
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and
| | - Jae Hwan Cho
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and
| | - Jae-Woo Park
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and
| | - Kun-Bo Park
- 2Division of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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Teo AQA, Thomas AC, Hey HWD. Sagittal alignment of the cervical spine: do we know enough for successful surgery? JOURNAL OF SPINE SURGERY 2020; 6:124-135. [PMID: 32309651 DOI: 10.21037/jss.2019.11.18] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the past decade, there has been growing interest in the sagittal alignment of the cervical spine and its correlation to clinical outcomes. It is now known that cervical lordosis is not universally physiological and should not be pursued in all patients undergoing surgery. Rather, it is increasingly understood that it is how these angular parameters (lordosis or kyphosis) interact with translational parameters that is reflective of overall cervical spine and whole spine balance, which in turn impacts patient outcomes. This review synthesises currently available evidence relating to the sagittal alignment of the cervical spine. Radiographic assessment of the cervical spine including horizontal gaze is discussed and alignment in physiological and pathological states analysed. The interdependence of spinal segments is reviewed, with cervical alignment correction influencing the adjacent thoracic spine, and similarly lumbar lordosis (LL) and global balance correction changing cervical spine alignment. Cervical kyphosis with associated cervical sagittal imbalance is known to lead to poorer post-operative outcomes, and this dichotomy in outcomes has not been shown to improve even with alignment correction. Further work is required to uncover the extent to which cervical spine alignment correction should be attempted toward improved patient outcomes, in order to plan and deliver patient-specific surgical realignment targets.
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Affiliation(s)
- Alex Quok An Teo
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Andrew Cherian Thomas
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Igawa T, Isogai N, Suzuki A, Kusano S, Sasao Y, Nishiyama M, Funao H, Ishii K. Establishment of a novel rehabilitation program for patients with dropped head syndrome: Short and intensive rehabilitation (SHAiR) program. J Clin Neurosci 2020; 73:57-61. [PMID: 31987630 DOI: 10.1016/j.jocn.2020.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/05/2020] [Indexed: 12/01/2022]
Abstract
The pathophysiology of dropped head syndrome (DHS) remains unknown, and its treatment algorithm and indication are not standardized. Here, we established a novel rehabilitation program, short and intensive rehabilitation program for DHS (SHAiR program), consisting of cervical paraspinal muscles exercise, range of motion exercise, cervical and thoracic mobilization, deep cervical flexor muscle exercise, hip lift exercise, anterior pelvic tilt exercise, and walking exercise. The aim of this study was to evaluate the clinical effectiveness of this program. We reviewed clinical outcomes for five consecutive patients with DHS who underwent the SHAiR program (SHAiR group). The outcomes were compared with those of other five patients with DHS who received exercise instruction (control group). Demographic data, the duration from onset of DHS, the apex of sagittal kyphosis on the lateral radiographs, and clinical outcomes including the ability to maintain normal horizontal gaze, chin brow vertical angle, and numerical rating scale (NRS) were evaluated at the initial visit and final follow-up at 7.5 months. There was no significant difference between the two groups in terms of demographic and radiographic data. The ability of horizontal gaze and NRS of cervical pain improved rapidly for all five patients in the SHAiR group as compared to no improvement for all patients in the control group. Rehabilitation for DHS was considered effective not only for localized rehabilitation such as exercise for training cervical extensor muscle function but also exercises for thoracolumbar posture improvement and the psoas muscle.
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Affiliation(s)
- Tatsuya Igawa
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan; Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Physical Therapy, Faculty of Health Science, International University of Health and Welfare, 2600-1, Kitakanemaru, Ohtawara, Tochigi 324-8501, Japan
| | - Norihiro Isogai
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan
| | - Akifumi Suzuki
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Shusuke Kusano
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Yutaka Sasao
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan
| | - Makoto Nishiyama
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan
| | - Haruki Funao
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan
| | - Ken Ishii
- Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan.
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49
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Diebo BG, Shah NV, Messina JC, Naziri Q, Post NH, Riew KD, Paulino CB. Restoration of Global Sagittal Alignment After Surgical Correction of Cervical Hyperlordosis in a Patient with Emery-Dreifuss Muscular Dystrophy: A Case Report. JBJS Case Connect 2020; 10:e0003. [PMID: 31899720 DOI: 10.2106/jbjs.cc.19.00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a rare cervical hyperlordotic deformity in a 19-year-old woman with Emery-Dreifuss muscular dystrophy and concomitant scoliosis. After standard posterolateral instrumentation and fusion of C2-T1 and extensive soft-tissue release, her neck pain improved and unassisted maintenance of cervical alignment and horizontal gaze were preserved through an 8-year follow-up. More importantly, she exhibited reciprocal correction of compensatory global sagittal malalignment, including lumbar lordosis. CONCLUSIONS This case highlights the importance of full-spine analysis for all patients with spinal deformity to identify and differentiate primary driver(s) of deformity from compensatory mechanisms to individualize treatment toward what truly drives the patient's disability.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York
| | - James C Messina
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York.,Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Nicholas H Post
- Department of Neurosurgery, Brookdale University Hospital Medical Center, Brooklyn, New York
| | - K Daniel Riew
- Department of Orthopaedic Surgery, The Daniel and Jane Och Spine Hospital at New York-Presbyterian, Columbia University Medical Center, New York, New York
| | - Carl B Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York
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50
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Oakley PA, Ehsani NN, Harrison DE. Repeat Radiography in Monitoring Structural Changes in the Treatment of Spinal Disorders in Chiropractic and Manual Medicine Practice: Evidence and Safety. Dose Response 2019; 17:1559325819891043. [PMID: 31839759 PMCID: PMC6900628 DOI: 10.1177/1559325819891043] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 12/18/2022] Open
Abstract
There is substantial evidence for normal relationships between spine and postural
parameters, as measured from radiographs of standing patients. Sagittal balance,
cervical lordosis, thoracic kyphosis, lumbar lordosis, pelvic tilt, and the more
complex understanding of the interrelations between these essential components
of normal stance have evolved to where there are known, established thresholds
for normalcy. These spinal parameters are reliably measured from X-ray images
and serve as goals of care in the treatment of spine and postural disorders.
Initial and follow-up spinal imaging by X-ray is thus crucial for the practice
of contemporary and evidence-based structural rehabilitation. Recent studies
have demonstrated that improvement in the spine and posture by nonsurgical
methods offers superior long-term patient outcomes versus conventional methods
that only temporarily treat pain/dysfunction. Low-dose radiation from repeated
X-ray imaging in treating subluxated patients is substantially below the known
threshold for harm and is within background radiation exposures. Since
alternative imaging methods are not clinically practical at this time, plain
radiography remains the standard for spinal imaging. It is safe when used in a
repeated fashion for quantifying pre–post spine and postural subluxation and
deformity patterns in the practice of structural correction methods by
chiropractic and other manual medicine practices.
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