Greater cervical kyphosis during flexion increases the risk of kyphotic deformity after laminoplasty in patients with cervical spondylotic myelopathy

Kyphotic deformity following the loss of cervical lordosis can lead to unfavourable neurological recovery after cervical laminoplasty (CLP); therefore, it is essential to identify its risk factors. Recent studies have demonstrated that the dynamic parameters of the cervical spine, based on baseline flexion/extension radiographs, are highly useful to estimate the loss of cervical lordosis after CLP. However, it remains unclear whether such dynamic parameters can predict kyphotic deformity development after CLP. Hence, the present study aimed to investigate whether the dynamic parameters could predict kyphotic deformity in patients with cervical spondylotic myelopathy (CSM) after CLP. This retrospective study included 165 patients, consisting of 10 and 155 patients with and without cervical kyphosis of C2-C7 angle ≤ -10° at the final follow-up period, respectively. Among the static and dynamic parameters of the cervical spine, greater cervical kyphosis during flexion (fC2-C7 angle) demonstrated the best discrimination between these two cohorts, with an optimal cutoff value of -27.5°. Meanwhile, greater gap range of motion (gROM = flexion ROM - extension ROM ) had the highest ability to predict a loss of ≥ 10° in C2-C7 angle after CLP, with an optimal cutoff value of 28.5°. This study suggests that in patients with CSM, fC2-C7 angle ≤ -25° on baseline radiographs is a potential risk for kyphotic deformity after CLP. In clinical practice, the patients with this criterion (fC2-C7 angle ≤ -25°) along with gROM ≥ 30° are at high risk of developing significant kyphotic deformity after CLP.

What Happens to Sagittal Alignment Following Laminoplasty Versus Laminectomy and Fusion?

OBJECTIVE

Laminectomy and fusion (LF) and laminoplasty (LP) are 2 sucessful posterior decompression techniques for cervical myelo-radiculopathy. There is also a growing body of evidence describing the importance of cervical sagittal alignment (CSA) and its importance in outcomes. We investigated the difference between pre- and postoperative CSA parameters in and between LF or LP. Furthermore, we studied predictive variables associated with change in cervical mismatch (CM).

METHODS

This is a retrospective cohort study of adults with cervical myeloradiculopathy in a single healthcare system. The primary outcomes are intra- and inter-cohort comparison of LF versus LP radiographic parameters at pre- and postoperative time points. A secondary multivariable analysis of predictive factors was performed evaluating factors predicting postoperative CM.

RESULTS

Eighty nine patients were included; 38 (43%) had LF and 51 (57%) underwent LP. Both groups decreased in lordosis (LF 11.4° vs. 4.9°, P = 0.01; LP 15.2° vs. 9.1°, P < 0.001), increased in cSVA (LF 3.4 vs. 4.2 cm, P = 0.01; LP 3.2 vs. 4.2 cm, P < 0.001), and increased in CM (LF 22.0° vs. 28.5°, P = 0.02; LP 16.8° vs. 22.3°, P = 0.002). There were no significant differences in the postoperative CSA between groups. No significant predictors of change in pre- and postoperative CM were found.

CONSLUSIONS

There were no significant pre-or postoperative differences following the 2 procedures, suggesting radiographic equipoise in well indicated patients. Across all groups, lordosis decreased, cSVA increased, and cervical mismatch increased. There were no predictive factors that led to change in cervical mismatch.

Early radiographic outcomes after anterior cervical discectomy and fusion with anatomic versus lordotic cages

Background

Anterior cervical discectomy and fusion (ACDF) interbody implants are shaped anatomically, with a convex superior aspect, or lordotically, with an angle and flat surfaces. However, the effect of implant shape on cervical sagittal balance (CSB) is not well described.

Methods

Of the 192 cases reviewed from 2018 to 2019, 118 were included with matching pre- and postoperative imaging. Cases were categorized by interbody implant type (anatomic or lordotic) and number of levels fused (1-level, 2-level, etc.). SurgiMap was used to measure cervical lordosis (CL), C2-C7 sagittal vertical axis (cSVA), T1 slope (T1S), and T1S minus CL (T1S-CL) on pre- and postoperative imaging. Pre- and postoperative parameters were compared within and between each cohort. Change in CL (ΔCL), cSVA (ΔcSVA), and T1S-CL (ΔT1S-CL) were calculated as the difference between pre- and postoperative values and were compared accordingly (1) anatomic versus lordotic and (2) 1-level versus 2-level versus 3-level fusion.

Results

Thirty-nine (33.1%), 57 (48.3%), and 22 (18.6%) cases comprised the anatomic, lordotic, and mixed (anatomic and lordotic) groups, respectively. ACDFs improved CL and T1S-CL by 5.71° (p<.001) and 3.32° (p<.01), respectively. CL was improved in the lordotic (5.27°; p<.01) and anatomic (4.57°; p<.01) groups, while only the lordotic group demonstrated improvement in T1S-CL (3.4°; p=.02). There were no differences in ΔCL (p=.70), ΔcSVA (p=.89), or ΔT1S-CL (p=.1) between the groups. Two- and 3-level fusions improved CL by 7.48° (p<.01) and 9.62° (p<.01), and T1S-CL by 4.43° (p<.01) and 5.96° (p<.01), respectively.

Conclusions

Overall, ACDFs significantly improved CL and T1S-CL however, there were no differences in CSB correction between the anatomic and lordotic groups. Two- and 3-level fusions more effectively improved CL (vs. single-level) and T1S-CL (vs. 3-level). These results suggest that implants should continue to be personalized to the patient's anatomy, however, future research is needed to validate these findings and incorporate the effects of preoperative deformities.

Effect of long-term cervical extensor exercise program on functional disability, pain intensity, range of motion, cervical muscle mass, and cervical curvature in young adult population with chronic non-specific neck pain: a randomized controlled trial

BACKGROUND

The prevalence of chronic non-specific neck pain (CNNP) is on the rise among the young adult population. We herein aimed to compare the effects of long-term specific cervical extensor training and stretching exercises on improving this chronic disorder in young adults.

METHODS

In this prospective, randomized, controlled study, 70 participants aged 18-35 years with CNNP and cervical lordosis loss were included. The participants were assigned to undergo either specific cervical extensor training (observation group) or perform usual stretching exercises (control group). The exercise duration was set at 12 months, with 9 months at the clinic and 3 months at home. The outcome assessments included changes in the neck disability index, visual analog scale from baseline, cervical range of motion (CROM), cross-sectional areas (CSAs) of cervical extensors, and cervical curvature from baseline. The outcome measures were compared between groups at 3, 6, and 12 months of follow-up.

RESULTS

All 70 participants underwent randomization, and no significant differences in demographics and baseline data were found between the two groups. The observation group showed a greater improvement in neck disability index and visual analog scale scores at the 12-month follow-up than the control group. Additionally, a more substantial increase in CROM and CSAs of cervical extensors was observed in the observation group at the 6-month and 12-month follow-ups (P < 0.05). Although more participants in the observation group achieved cervical lordosis at the 12-month follow-up, the difference was marginally nonsignificant (9% in the control group vs. 28% in the observation group, P = 0.075).

CONCLUSIONS

In young adults with CNNP, long-term specific cervical extensor training was associated with a more significant clinically meaningful improvement in disability, pain, and CROM than stretching exercises. The increased CSAs of cervical extensors may potentially contribute to the restoration of cervical lordosis. Trial registration The study is registered at the Chinese domestic clinical trial (ChiCTR2000040009) at Chictr.org. The date of registration: November 18, 2020.

Favorable cervical extension capacity preventing loss of cervical lordosis after laminoplasty due to spontaneous restoration of initial lordosis

BACKGROUND CONTEXT

Cervical laminoplasty is a common approach for the treatment of multilevel cervical spondylotic myelopathy (CSM). Postoperative loss of cervical lordosis (LCL) was associated with lower extension motion of the cervical spine before laminoplasty.

PURPOSE

To analyze the possible causes of preoperative cervical extension capacity affecting LCL after laminoplasty by evaluating the changes in cervical lordosis (CL) at different stages.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

Seventy-two patients undergoing laminoplasty due to multilevel CSM.

OUTCOME MEASURES

Radiographic parameters included CL, extension CL (eCL), flexion CL (fCL), range of motion (ROM), extension ROM (eROM), flexion ROM (fROM) and LCL. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) and neck disability index (NDI) score.

METHODS

The data were recorded before surgery and at 3- and 24-month follow-up. All patients completed a cervical extension test preoperatively. A receiver operating characteristic (ROC) curve of eROM was constructed to discriminate the patients with and without postoperative kyphotic deformity.

RESULTS

According to the optimal cut-off value of eROM, the patients were divided into two groups: extension group (eROM≥9.3°) and control group (eROM<9.3°). The radiographic outcomes demonstrated no significant differences in CL, eCL, fCL and ROM between the two groups. Both eROM and fROM were significantly different in the two groups. There was a significant change in CL in the extension group at 3-month follow-up and in the control group at 24-month follow-up. The extension group exhibited significantly lower LCL compared with the control group at follow-up. No significant difference between the two groups was noted in the JOA recovery rate, while the NDI score was significantly different at 24-month follow-up. The positivity ratio of the extension test was significantly greater in the extension group than that in the control group.

CONCLUSIONS

eROM in patients with favorable preoperative cervical extension capacity (eROM≥9.3°) consisted of the actual extension capacity and compensatory flexion. The cervical alignment would be spontaneously restored to its initial lordosis in the short term after laminoplasty. These patients had no substantial LCL at 24-month follow-up and would be good candidates for laminoplasty.

Assessing Range of Motion Gap in Circumferential Surgery for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament

OBJECTIVE

Only a few studies have investigated the gap range of motion (gROM) in cervical myelopathy or deformity caused by ossification of the posterior longitudinal ligament (OPLL). The aim of this study is to investigate the correlation between the individual gROM and the postoperative clinical outcomes of patients with OPLL.

METHODS

Consecutive patients of cervical myelopathy caused by OPLL were analyzed retrospectively. The clinical outcomes were evaluated using Visual Analogue Scale scores of the neck and arm pain and the Japanese Orthopaedic Association scores. Radiologic measurements included flexion ROM (fROM), which was defined as the difference of cervical lordosis in flexion and neutral positions, extension ROM (eROM), defined as the difference between neutral and extension positions, and gROM, defined as the difference between fROM and eROM. Patients were grouped by the values of gROM, and comparisons of all outcomes were made between the groups.

RESULTS

A total of 42 patients underwent surgery. The patients with greater gROM did not differ from those with smaller gROM by demographic characteristics. During follow-up (mean 45.8 months), both groups had similar improvements, but the C5 palsy rates were higher in the greater gROM group than in the smaller gROM group (71% and 22%, P < 0.05).

CONCLUSIONS

Simultaneous circumferential decompression and fixation is an effective surgical option for patients with cervical myelopathy caused by OPLL. A higher rate of postoperative C5 palsy was observed in the patients with greater gROMs after surgery, although all patients presented with similar clinical improvements.

Upper and lower cervical alignment parameters measured on supine magnetic resonance imaging with the occipital slope as a key marker of cervical alignment

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.

Risk Factors for Postoperative Loss of Lordosis, Cervical Kyphosis, and Sagittal Imbalance After Cervical Laminoplasty

OBJECTIVE

A retrospective cohort study was undertaken to elucidate the risk factors of loss of cervical lordosis (LCL), kyphotic deformity, and sagittal imbalance after cervical laminoplasty.

METHODS

A total of 108 patients who underwent laminoplasty to treat cervical myelopathy and were followed for ≥2 years were included. Logistic regression analysis and multiple regression analysis were performed to identify preoperative risk factors of LCL, kyphotic deformity (cervical lordosis <0°), and sagittal imbalance (sagittal vertical axis >40 mm) at postoperative 2 years.

RESULTS

Within multivariate multiple regression analysis, C2-C7 lordosis (P = 0.002), and C2-C7 extension capacity (P<0.001) showed significant association with LCL. Furthermore, age (P = 0.043) and C2-C7 lordosis (P = 0.038) were significantly associated with postoperative kyphosis. Receiver operating characteristic curve analysis for postoperative kyphosis showed that preoperative C2-C7 lordosis of 10.5° had a sensitivity and specificity of 81.3% and 82.4%, respectively. Preoperative K-line tilt (P = 0.034) showed a significant association with postoperative cervical sagittal imbalance at postoperative 2 years. Receiver operating characteristic curve analysis showed that a K-line tilt cutoff value of 12.5° had a sensitivity and specificity of 78.6% and 77.7%, respectively, for predicting postoperative sagittal imbalance.

CONCLUSIONS

Higher preoperative C2-C7 lordosis and less preoperative cervical extension capacity were risk factors of LCL. Small preoperative C2-C7 lordosis <10.5° and younger age were risk factors of postoperative kyphosis. Furthermore, a greater K-line tilt would increase the risk of postoperative sagittal imbalance, with a cutoff value of 12.5°.

Impact of C3 laminectomy on cervical sagittal alignment in cervical laminoplasty: a prospective, randomized controlled trial comparing clinical and radiological outcomes between C3 laminectomy with C4-C6 laminoplasty and C3-C6 laminoplasty

BACKGROUND CONTEXT

C3 laminectomy in cervical laminoplasty is a modified laminoplasty technique that can preserve the semispinalis cervicis muscle attached to the C2 spinous process. Several previous studies have shown that this technique can lead to better outcomes of postoperative axial neck pain and C2-C3 range of motion (ROM) than conventional cervical laminoplasty. However, there is still a lack of understanding of total and proportional postoperative cervical sagittal alignment outcomes.

PURPOSE

To assess the effects of C3 laminectomy in cervical laminoplasty on postoperative cervical alignment and clinical outcomes.

DESIGN

A single-center, patient-blinded, randomized controlled trial.

PATIENT SAMPLE

We included consecutive 126 patients diagnosed with cervical spondylotic myelopathy (CSM) or ossification of posterior longitudinal ligament (OPLL) who were scheduled for cervical laminoplasty from March 2017 to January 2020.

OUTCOME MEASURES

The primary outcome measures were C2-C7 Cobb angle (CA) and neck disability index (NDI). Secondary outcomes measures included other clinical outcomes and radiographic parameters including segmental Cobb angle and presence of C2-C3 interlaminar fusion.

METHODS

Patients were randomly allocated to either the C3 laminectomy with C4-C6 laminoplasty group (LN group) or the C3-C6 laminoplasty group (LP group) at a 1:1 ratio. Laminoplasty was performed using a unilateral open-door technique and stabilized with titanium mini plates. A linear mixed model analysis was employed to examine the longitudinal data from postoperative 1-year through 3-year. Additional analysis between three types of cervical sagittal alignment morphology was done.

RESULTS

Among 122 patients who were randomly allocated to one of two groups (LN group, n=61; LP group, n=61), modified intent-to-treat analysis was done for 109 patients (LN group, n=51, LP group, n=58) who had available at least a year of postoperative data. Postoperative C2-C7 CA was not significantly different between the two groups. However, NDI was significantly different between the two groups (12.8±1.0 in the LN group vs 8.6±1.0 in LP group, p=.005), which exceeded the minimum clinically important difference (MCID). The postoperative C2-C3 CA was significantly greater in the LN group (7.1±0.5° in LN group vs 3.2±0.5° in LP group, p<.001) while C4-C7 CA was significantly smaller in the LN group (3.9±0.8° in LN group vs 7.7±0.7° in LP group, p<.001) with greater cSVA in the LN group (31.6±1.4 mm in LN group vs 25.5±1.3 mm in LP group at postoperative 3-year, p=.002). Postoperative Euro-Quality of Life-5 Dimension (EQ-5D), numerical rating scores for neck pain (NRS-N) were significantly better in the LP group than in the LN group (all p<.05) and only EQ-5D surpassed the MCID. The C2-C3 fusion rate was significantly different between the LN group (9.8%) and the LP group (44.8%) (p<.001). The LN group showed a higher prevalence of a specific cervical alignment morphology characterized by a sigmoid shape with proximal lordosis and distal kyphosis (S curve). This S curve demonstrated significantly unfavorable outcomes across multiple outcome variables.

CONCLUSION

The impact of C3 laminectomy in cervical laminoplasty on postoperative kyphosis among patients with CSM or OPLL did not significantly differ from that of C3-C6 laminoplasty. However, C3 laminectomy in cervical laminoplasty might result in an unfavorable clinical outcome with an unbalanced cervical sagittal alignment characterized by a sigmoid shape with proximal lordosis and distal kyphosis.

Scapular dyskinesis and loss of cervical lordosis in myofascial pain syndrome and its effects on pain and posture disorders

Objectives

This study aimed to evaluate scapular dyskinesia and loss of cervical lordosis in myofascial pain syndrome and its effects on pain and posture disorders.

Patients and methods

In this cross-sectional study, 101 individuals (74 females, 27 males; mean age: 44.3±8.8 years; range, 25 to 60 years) with chronic neck pain were recruited between January 2021 and February 2021. Demographic and clinical data of the patients were recorded. Visual Analog Scale (VAS), posture evaluation form, the scapular dyskinesia test, the lateral scapular shift test, and Cobb's methods for cervical angle measurements were used in the evaluation of the patients.

Results

In the study population, 52.25% of patients had loss of cervical lordosis, and 44.5% of patients had scapular dyskinesia. It was observed that the VAS activity score was significantly higher in individuals with loss of cervical lordosis, all VAS scores and pain duration were significantly higher in individuals with scapular dyskinesia (p<0.05). Shoulder elevation, rounded shoulder, forward head posture, and kyphosis were significantly higher in patients with scapular dyskinesia, while thoracic kyphosis was significantly higher in patients with both scapular dyskinesia and loss of cervical lordosis (p<0.05). The presence of trigger points was found to be significantly higher in patients with scapular dyskinesia and in patients with both scapular dyskinesia and loss of cervical lordosis (p<0.05).

Conclusion

In patients with chronic neck pain diagnosed with myofascial pain syndrome, the presence of loss of cervical lordosis and scapular dyskinesia have negative effects on pain and posture.

Analysis of Components of Upper Cervical Lordosis in Asymptomatic Lordotic and Kyphotic Subjects

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.

Minimally Invasive Posterior Cervical Fusion: A Handsome Option

Cervical spondylosis is the leading cause of cervical myelopathy. When surgery is indicated, it is commonly addressed through an anterior or posterior cervical approach, such as cervical discectomy and fusion (ACDF) or laminectomy and fusion (LMF). Besides their own merits, each one has specific approach- or device-related complications, such as dysphagia, significant postoperative pain, wound infection, adjacent segment degeneration (ASD), and pseudoarthrosis. Through a tissue-sparing minimally invasive technique, posterior cervical fusion (PCF) has shown unfolding compelling evidence of biomechanical stability, good clinical outcomes, and high fusion rates, with fewer complications and better econometrics. On the basis of our own experience, we discuss here the indications, advantages, and drawbacks of minimally invasive PCF.

Anterior Bone Loss in Cervical Disc Arthroplasty Correlates with Increased Cervical Lordosis

OBJECTIVE

Although cervical disc arthroplasty (CDA) has reportedly been associated with similarly low incidences of complications to anterior cervical discectomy and fusion, the phenomenon of anterior bone loss (ABL) is unique to CDA and has only recently gained notice. This study thus aimed to investigate the incidence of ABL and its correlation with cervical alignment post-operation.

METHODS

Consecutive patients who received CDA for herniated disc or spondylosis were retrospectively reviewed. The development and extent of ABL was detected by comparison of preoperative and postoperative serial images for the relative position of the anterior vertebral body with the CDA devices and graded into 3 levels: grade 1 (minor bone loss), grade 2 (anterior portion of the vertebral body without exposure of the artificial disc), and grade 3 (anterior portion of the vertebral body with exposure of the device).

RESULTS

A total of 41 patients were analyzed with a mean follow-up of 24.1 months. Under serial radiologic examinations during follow-up, all patients (41 of 41 = 100%) had bone loss of various degrees, with grade 3 ABL the most common (30 of 41 = 73.1%). There were 8 and 3 patients who had grades 2 and 1 ABL, respectively. The changes of the Cobb angle (ΔCobb) trended towards higher grades of ABL.

CONCLUSIONS

During the mean follow-up of 2 years, ABL was a common radiologic finding. More than half of the patients (26 of 41, 63.4%) in the series gained cervical lordosis (ΔCobb >0) after CDA. These patients with increased cervical lordosis (ΔCobb >0) after CDA had higher grades of ABL.

Is the cervical lordosis a key biomechanical biomarker in cervicogenic headache?: a Chiropractic Biophysics® case report with follow-up

[Purpose] To present the successful structural improvement in cervical lordosis in a patient suffering from cervicogenic headache having cervical kyphosis. [Participant and Methods] A 26 year old female presented with the primary complaint of headache. Radiography demonstrated a cervical kyphosis. Chiropractic BioPhysics^® methods were used to restore the cervical spine alignment. Twenty-five treatments were given over 8 weeks. A 2.5 year follow-up was also reported. [Results] Radiography showed a dramatic increase in cervical lordosis following initial treatment. The patient also reported substantial reductions in headache frequency and severity as well as other bodily improvements, reduced disability and improved quality of life. The long-term follow-up showed a maintenance of lordosis correction and patient wellness. [Conclusion] A cervical kyphosis was reversed back to a normal lordosis in 8 weeks and coincided with dramatic resolution of cervicogenic headache in a young female. The cervical lordosis may be a key biomechanical biomarker in cervicogenic headache.

Improving the cervical lordosis relieves neck pain and chronic headaches in a pediatric: a Chiropractic Biophysics® (CBP®) case report with a 17-month follow-up

[Purpose] To present the case of a dramatic improvement in the cervical lordosis and relief from chronic headaches and neck pain in a pediatric having a recent neck trauma. [Participant and Methods] A 10 year old male presented with recent neck trauma, neck pain and pre-existing chronic headaches. Cervical range of motion was limited with pain. X-ray analysis showed dramatic loss of cervical lordosis and an acute atlantoaxial rotatory fixation. Chiropractic Biophysics technique methods incorporating spinal manual adjustments, cervical extension traction and corrective exercises were used to restore normal cervical lordosis. Treatments were performed intensively over 6.5-weeks, with a 17-month long-term follow-up. [Results] The pediatric patient responded well to treatment with near complete resolution of cranio-cervical complaints. The cervical lordosis was corrected to age-appropriate magnitude, the coronal symmetry was restored, and both were maintained after nearly 1.5 years. [Conclusion] Chiropractic Biophysics technique which includes the cervical extension traction using the pediatric Denneroll orthotic was effective in restoring lordosis in a pediatric patient with cervical kyphosis and chronic headaches presenting with recent neck pains from a traumatic origin. Routine X-ray of the cervical spine is recommended for patients presenting with craniocervical symptoms as spine alignment is often overlooked as pathognomonic for these conditions.

Does the postoperative cervical lordosis angle affect the cervical rotational range of motion after cervicothoracic multilevel fusion?

BACKGROUND

Laminectomy and multilevel fusion in patients with degenerative cervical myelopathy lead to severe restriction in cervical spine mobility. Since fusions from C₂ to the thoracic spine result in a permanently stiff subaxial cervical spine, it seems obvious to restore physiological cervical lordosis, especially with regard to sagittal balance. However, there are reports that a fusion in a more lordotic position leads to a reduction of rotational cervical range of motion in the still mobile segments C₀-C₂. This study investigates the relationship between postoperative cervical lordosis and the objective rotational range of motion and subjective restriction.

METHODS

In this single-center, retrospective cohort study, patients with degenerative cervical myelopathy operated via laminectomy and fusion from C₂ to the thoracic spine were included. X-ray imaging was evaluated for common lordosis parameters. The patient-reported rotational restriction of cervical spine mobility was acquired by a five-step score. Objective rotational range of motion was measured. The radiological parameters for cervical lordosis (C₂-C₇ lordotic angle, C₂-C₇ Cobb angle) were correlated with the measurements and the patient-reported subjective scores.

FINDINGS

We found a significant, medium negative correlation between the measurements for rotation and the C₂-C₇ lordotic angle and a significant, large negative correlation to the C₂-C₇ Cobb angle. For subjective restriction, no or only small correlation was observed.

INTERPRETATION

We found significant negative correlations between radiological cervical lordosis and objective measurements for rotation. These results indicate that for this particular patient population, a stronger postoperative cervical lordosis does not seem favorable under the aspect of rotational range of motion.

Treatment of cervical myelopathy by posterior approach: Laminoplasty vs. laminectomy with posterior fixation, are there differences from a clinical and radiological point of view?

INTRODUCTION

Cervical degenerative myelopathy is a variable and progressive degenerative disease caused by chronic compression of the spinal cord. Surgical approaches for the cervical spine can be performed anteriorly and/or posteriorly. Regarding the posterior approach, there are 2 fundamental techniques: laminoplasty and laminectomy with posterior fixation (LPF). There is still controversy concerning the technique in terms of outcome and complications. The aim of the present work is to analyze from the clinical and radiological point of view these 2 techniques: laminoplasty and LPF.

MATERIALS AND METHODS

A historical cohort of 39 patients was reviewed (12 LFP and 27 laminoplasty) including patients operated in a 10 years period at the Hospital Universitario La Paz with a follow-up of 12 months after surgery was carried out. The clinical results were analyzed and compared using the Nurick scale and the modified Japanese Orthopaedic Association Scale (mJOA) and the radiological results using the Cobb angle, Sagittal Vertical Axis, T1 Slope and alignment (measured by Cobb-T1 Sloppe).

RESULTS

Significant differences were observed in the postoperative improvement of the Nurick scale (p = 0.008) and mJOA (p = 0.018) in the laminoplasty group. In LFP there is a tendency to a greater improvement, but statistical significance is not reached due to the low sample size of this group. No statistically significant differences were observed in the radiological variables. Regarding the total number of complications, a higher number was observed in the laminoplasty group (7 cases) versus LFP (one case), but no statistically significant differences were observed.

CONCLUSIONS

Laminoplasty and LFP are both safe and effective procedures in the treatment of cervical degenerative myelopathy. The findings of our study demonstrate statistically significant clinical improvement based on the Nurick and mJOA scales with laminoplasty. No significant differences in terms of complications or radiological variables were observed between the 2 techniques.

Analyzing the Significance of T1 Slope minus Cervical Lordosis in Patients with Anterior Cervical Discectomy and Fusion Surgery

Objective

Accurate measurement of T1 slope (a component of T1s minus cervical lordosis [CL]) is often constrained by anatomical limitations. In this situation, efforts should be made to find the exact meaning of T1s-CL and whether there are any alternatives to it.

Methods

We enrolled 117 patients who received two-level anterior cervical discectomy and fusion (ACDF). Occipital slope, C2 slope (C2s), C7 slope (C7s), T1, O-C2 angle (O-C2A), C2-7 angle (C2-7A), O-C7 angle (O-C7A), T1s-CL, C7-T1 angle (C7-T1A), and C2-7 sagittal vertical axis were measured. We determined 16° (T1s-CL) as the reference point for dividing subjects into the mismatch group and the balance group, and a comparative analysis was performed.

Results

The mean value of C7-T1A was constantly maintained within 2.6° peri-operatively. In addition, C2s and T1s-CL showed the same absolute change (Δ|0.8|°). The mean values of T1s-CL of the mismatch and balance groups were 23.0° and 7.6°, respectively. The five factors with the largest differences between the two groups were as follows : C2s (Δ13.3°), T1s-CL (Δ15.4°), O-C2A (Δ8.7°), C2-7A (Δ14.7°), and segmental angle (Δ7.9°) before surgery. Only four factors showed statistically significant change between the two groups after ACDF : T1s-CL (Δ4.0° vs. Δ0.2°), C2s (Δ3.2° vs. Δ0.7°), O-C2A (Δ2.6° vs. Δ1.3°), C2-7A (Δ6.3° vs. Δ1.3°). A very strong correlation between T1s-CL and C2s was also found (r=|0.88–0.96|).

Conclusion

C2s itself may be the essential key to represent T1s-CL. The amounts and directions of change of these two factors (T1s-CL and C2s) were also almost identical. The above phenomenon was re-confirmed once again through the correlation analysis.

Cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis and assessment of its alteration with surgery: a retrospective, multi-centric study

PURPOSE

To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery.

METHODS

Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared-the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction.

RESULTS

At baseline, TK was 29.8° ± 16°, cervical lordosis (CL) was - 1° ± 14°, lumbar lordosis (LL) was - 57.1° ± 21°, C2-C7 sagittal vertical axis (SVA) was 16 ± 14 mm and C7-S1 SVA was - 15 ± 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment-TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. Neither CL nor C2-C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively.

CONCLUSION

There is a high incidence of cervical kyphosis at baseline in AIS patients-more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery-improvement in CL correlates weakly with sagittal correction of the structural curve.

Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials

[Purpose] To systematically review the literature on the use of cervical extension traction methods for increasing cervical lordosis in those with hypolordosis and cervical spine disorders. [Methods] Literature searches for controlled clinical trials were performed in Pubmed, PEDro, Cochrane, and ICL databases. Search terms included iterations related to the cervical spine, neck pain and disorders, and extension traction rehabilitation. [Results] Of 1,001 initially located articles, 9 met the inclusion/exclusion criteria. The trials demonstrated increases in radiographically measured lordosis of 12-18°, over 5-15 weeks, after 15-60 treatment sessions. Untreated controls/comparison groups not receiving extension traction showed no increase in cervical lordosis. Several trials demonstrated that both traction and comparison treatment groups experienced immediate pain relief. Traction treatment groups maintained their pain and disability improvements up to 1.5 years later. Comparative groups not receiving lordosis improvement experienced regression of symptoms towards pre-treatment values by 1 years' follow-up. [Conclusion] There are several high-quality controlled clinical trials substantiating that increasing cervical lordosis by extension traction as part of a spinal rehabilitation program reduces pain and disability and improves functional measures, and that these improvements are maintained long-term. Comparative groups who receive multimodal rehabilitation but not extension traction experience temporary relief that regresses after treatment cessation.

Surgical increase in thoracic kyphosis predicts increase of cervical lordosis after thoracic fusion for adolescent idiopathic scoliosis

PURPOSE

The modification of cervical lordosis (CL) after adolescent idiopathic scoliosis (AIS) surgery is influenced by the correction of thoracic hypokyphosis. The quantification of the increase of CL as a function of the increase of thoracic kyphosis (TK) has never been calculated.

METHODS

A total of 92 consecutive AIS patients who underwent a posterior thoracic selective fusion, corrected by simultaneous translation on 2 rods technique, with minimum 24-month follow-up, were analyzed from a prospective database. We evaluated global sagittal kyphosis and lordosis. CL was divided by the horizontal line in proximal (PCL) and distal cervical lordosis (DCL), likewise TK in proximal (PTK) and distal TK (DTK), and lumbar lordosis (LL) in proximal (PLL) and distal LL (DLL).

RESULTS

The mean TK gain was 16°, 14° and 28° in the whole cohort, normokyphosis group and hypokyphosis group, respectively. The mean DCL gain was, respectively, 9°, 7° and 20° and the mean CL gain 8°, 5° and 21°. There was a strong correlation between TK gain and CL gain (coefficient = 0.86) and between TK gain and DCL gain (coefficient = 0.74). The regression equation was defined as DCLgain = - 3 + 0.75 × TKgain (p < 0.0001) corresponding on average to 60% of the TK gain.

CONCLUSION

60% of the TK gain was transferred to DCL gain. Correlations reflect the geometrical equivalence between PTK and DCL. The use of sagittal global measurements shows that DCL is equivalent to PTK and can be expressed as a function of pelvic parameters (DCL = PT + LL-PI). DCL must be considered to optimize the postoperative sagittal alignment of the spine.

Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: A 2-year pilot randomized controlled trial

BACKGROUND

To investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) via the addition of sagittal cervical spine alignment correction.

DESIGN

Pilot, parallel-group, randomized controlled trial.

PARTICIPANTS

60 patients with CGH, straightening of the cervical lordosis, and forward head posture (FHP) were randomly assigned using permuted-block randomization either to a control (n = 30) or an experimental group (n = 30).

INTERVENTIONS

Subjects in both groups received a multimodal program where the denneroll cervical spine extension traction orthotic was added to the experimental group only. Feasibility was assessed through recruitment rate, compliance rate, adherence rate, safety, and global satisfaction in addition to clinical outcome measures: FHP distance, cervical lordosis, headache frequency, headache disability inventory (HDI), headache impact test-6 (HIT-6), and daily defined dose (DDD). Evaluations were performed at: baseline, 10 weeks, 1 year follow up, and 2-year follow up. The assessor was blind to group allocation for all measured outcomes.

RESULTS

The recruitment rate was 60%, 78 % out of them completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded and greater overall satisfaction with the interventions was reported. Greater improvements were found for the experimental group's cervical lordosis (f = 259.9, P< < .001) and FHP (f = 142.5, P< < .001). At 10 weeks, both groups showed equal improvements in CGH outcomes: headache frequency (P = 0.07), HDI (P = 0.07), HIT-6 (P = .2), and DDD (P = .3). In contrast, at the 1-year and 2-year follow up, between group differences were found for all CGH outcomes, P < .00, indicating greater improvement in the experimental group.

CONCLUSION

The results indicated feasibility for recruitment rate, compliance rate, exercise session adherence, safety, and global satisfaction. At 1-year and 2-year follow-up, the addition of the denneroll orthotic device revealed positive influence on CGH management outcomes.

TRIAL REGISTRATION

The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR201605001650300).

Determining the Difference in Clinical and Radiologic Outcomes Between Expandable and Nonexpandable Titanium Cages in Cervical Fusion Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine.

METHODS

A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases.

RESULTS

Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P < 0.001; 1-level and 2-level, 6.81° vs. 4.31°, P < 0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017).

CONCLUSIONS

The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.

The treatment of dizziness by improving cervical lordosis: a Chiropractic BioPhysics® case report

[Purpose] To present the case of the relief of idiopathic dizziness and the reduction of neck pains and headache by the improvement in cervical alignment using Chiropractic BioPhysics^® technique. [Participant and Methods] A 57 year old female presented with 30 years of chronic dizziness, neck pains and headache. Multiple testing ruled out known causes of vertigo. The patient was diagnosed with idiopathic dizziness. The patient scored 56 points on the dizziness handicap inventory. The patient showed a cervical hypolordosis of −13.7° and anterior head translation of 27 mm. The patient underwent a multimodal treatment of spinal manipulation, cervical extension traction, neck exercises as well as initial electrical stimulation. Traction procedures were slowly progressive due to the severity of the dizziness symptoms. [Results] Over a period of 12-months and 115 treatments there was a 20° increase in cervical lordosis. The patient reported significant reduction in neck pains, headache and dizziness frequency and severity. The patient had a 44-point drop on the dizziness handicap inventory; dizziness symptoms were reported to be very rare. A 1.5 year follow-up showed stability of the symptom relief and a negligible score on the dizziness handicap inventory. [Conclusion] Cervical hypolordosis may be an under-diagnosed cause of idiopathic dizziness in some patients.

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

Objectives

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

Patients and methods

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

Results

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

Conclusion

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

The Effect of T1-Slope in Spinal Parameters After Cervical Disc Arthroplasty

BACKGROUND

Although patients with cervical kyphosis are not ideal candidates for cervical disc arthroplasty (CDA), there is a paucity of data on patients with a straight or slightly lordotic neck.

OBJECTIVE

To correlate cervical lordosis, T1-slope, and clinical outcomes of CDA.

METHODS

The study retrospectively analyzed 95 patients who underwent 1-level CDA and had 2-yr follow-up. They were divided into a high T1-slope (≥28°) group (HTSG, n = 45) and a low T1-slope (<28°) group (LTSG, n = 50). Cervical spinal alignment parameters, including T1-slope, cervical lordosis (C2-7 Cobb angle), and segmental mobility (range of motion [ROM]) at the indexed level, were compared. The clinical outcomes were also assessed.

RESULTS

The mean T1-slope was 28.1 ± 7.0°. After CDA, the pre- and postoperative segmental motility remained similar and cervical lordosis was preserved. All the clinical outcomes improved after CDA. The HTSG were similar to the LTSG in age, sex, segmental mobility, and clinical outcomes. However, the HTSG had higher cervical lordosis than the LTSG. Furthermore, the LTSG had increased cervical lordosis (ΔC2-7 Cobb angle), whereas the HTSG had decreased lordosis after CDA. Patients of the LTSG, who had more improvement in cervical lordosis, had a trend toward increasing segmental mobility at the index level (ΔROM) than the HTSG.

CONCLUSION

In this series, T1-slope correlated well with global cervical lordosis but did not affect the segmental mobility. After CDA, the changes in cervical lordosis correlated with changes in segmental mobility. Therefore, segmental lordosis should be cautiously preserved during CDA as it could determine the mobility of the disc.

Morphometric analysis of cervical interlaminar space for posterior surgical approach and decompression

PURPOSE

The purpose of this study is to provide a morphometric description of the bony margins of the interlaminar spaces by level in the cervical spine for guidance of safe posterior cervical surgical dissection and decompression. We also aim to describe the impact of increasing static cervical lordosis on the overlap between the lamina.

METHODS

Morphometric measurements of the interlaminar space were performed on 100 consecutive cervical spine CT scans of patients ranging in age from 18 to 50 years were selected. Three raters performed measurements of the interlaminar height measured using two techniques (true interlaminar height and surgical interlaminar height), and interlaminar width from C2-C3 to C7-T1.

RESULTS

In total, 100 patients were included. The true interlaminar height was greatest at C2-3, C3-4, C4-5 (5.2 ± 1.4-1.8 mm) and smallest at C6-7 (4.4 ± 1.3 mm). Surgical interlaminar height was greatest at C3-4 (4.2 ± 1.7) and smallest at C6-7 (3.0 ± 1.3 mm). The widest interlaminar space was observed at C3-4 (27.1 ± 2.1 mm) and most narrow at C7-T1 (20.9 ± 2.4 mm). Following multivariate regression, male gender was associated with greater interlaminar widths at each cervical level between C4 and T1 (Table 2). While greater patient height was associated with larger interlaminar height (true and surgical) and width at C2-3 and C4-5, weight was not independently associated with the interlaminar measurements. Increasing C2-C7 lordosis was significantly associated with decreasing true and surgical interlaminar heights at all levels except C7-T1, but was not associated with differences between interlaminar width.

CONCLUSION

The study provides a morphometric analysis of interlaminar anatomy in the cervical spine. Surgeons can apply this information in their pre-operative plan to safely approach the posterior cervical spine.

Is it Possible to Distinguish Cervicogenic Headache from Neck Pain with Cervicospinal Posture? A Single-Blind, Prospective Cross-Sectional Trial

BACKGROUND

Cervicogenic headache (CEH) is a type of headache that is considered to be originated from the upper cervical spine. There are conflicting results in studies showing changes in the cervical spine in patients with CEH.

OBJECTIVES

We aimed to compare the cervical radiographs of patients with CEH and nonspecific neck pain.

STUDY DESIGN

A single-blind, prospective study.

SETTING

The department of neurosurgery and physical medicine and rehabilitation in a university hospital.

METHODS

In this cross-sectional study; 45 women with CEH and 45 women with neck pain were involved. The pain assessment of the patients was done by the Visual Analog Scale (VAS), and the disability assessment was tested with the Neck Disability Index (NDI). General cervical lordosis (GCL) and upper cervical lordosis (UCL) angles were calculated on the lateral cervical x-ray. Clinical parameters including age, weight, height, pain (VAS), disability (NDI), and disease duration were recorded. Patients with CEH and neck pain were compared. Correlations between GCL, UCL, and pain assessment were analyzed.

RESULTS

Both groups were demographically similar. There was no significant difference at the lateral cervical x-ray measurements between CEH and neck pain groups (CEH group mean GCL = 19.2, UCL = 13.6; neck pain group mean GCL = 19.1, UCL= 14.8). The positive correlation between GCL and UCL in the neck pain group (r = 0.453; P = 0.002) was not found in the CEH group (P > 0.05).

LIMITATIONS

Anesthetic blockade was not used for the diagnosis. Also, the whole spinal alignment was not evaluated.

CONCLUSIONS

According to cervical lateral x-ray, there was no significant difference in posture in patients with CEH and neck pain.

Cervical Sagittal Alignment: Literature Review and Future Directions

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?

Vertebral Body Sliding Osteotomy for Cervical Myelopathy With Rigid Kyphosis

Cervical spondylotic myelopathy is surgically demanding when associated with rigid kyphosis. Posterior surgery cannot restore cervical lordosis, and adequate decompression is not possible with rigid kyphosis. Vertebral body sliding osteotomy (VBSO) is a safe and novel technique for anterior decompression in patients with multilevel cervical spondylotic myelopathy. It is safe in terms of dural tear, pseudarthrosis, and graft dislodgement, which are demonstrated at high rates in anterior cervical corpectomy and fusion. In addition, VBSO is a powerful method for restoring cervical lordosis through multilevel anterior cervical discectomy and fusion above and below the osteotomy level. It may be a feasible treatment option for patients with cervical spondylotic myelopathy and kyphotic deformity. This is a technical note and literature review that describes the procedures involved in VBSO.

Cervical sagittal alignment in adolescent high dysplastic developmental spondylolisthesis: how does the cervical spine respond to the reduction of spondylolisthesis?

Background

Although pelvic and related parameters have been well stated in lumbar developmental spondylolisthesis, cervical sagittal alignment in these patients is poorly studied, especially in high dysplastic developmental spondylolisthesis (HDDS). The purpose of this study is to investigate the sagittal alignment of the cervical spine in HDDS and how the cervical spine responds to reduction of spondylolisthesis.

Methods

Thirty-three adolescent patients with lumbar developmental spondylolisthesis who received preoperative and postoperative whole-spine x-rays were reviewed. They were divided into the HDDS group (n = 24, 13.0 ± 2.2 years old) and the low dysplastic developmental spondylolisthesis (LDDS) group (n = 9, 15.6 ± 1.9 years old). Spinal and pelvic sagittal parameters, including cervical lordosis (CL), were measured and compared between groups. In the HDDS group, the postoperative parameters were measured and compared with those before surgery.

Results

HDDS group had a higher proportion of cervical kyphosis (70.8% vs. 22.2%, P = 0.019), and there was a significant difference in CL between the two groups (− 8.5° ± 16.1° vs. 10.5° ± 11.8°, P = 0.003). CL was correlated with the Dubousset’s lumbosacral angle (Dub-LSA), pelvic tilt (PT), and thoracic kyphosis (TK). In the HDDS group, CL in patients with a kyphotic cervical spine was significantly improved after reduction of spondylolisthesis (− 16.4° ± 5.9° vs. − 3.6° ± 9.9°, P < 0.001). In the HDDS group, 46% (6/13) of the patients with postoperative Dub-LSA < 90° still had sagittal imbalance (sagittal vertical axis, [SVA] > 5 cm), while no sagittal imbalance was observed in patients with postoperative Dub-LSA > 90° (46% [6/13] vs. 0% [0/11], P = 0.016).

Conclusions

HDDS can lead to cervical kyphosis through a series of compensatory mechanisms. Reduction of spondylolisthesis and correction of lumbosacral kyphosis may correct the cervical kyphosis and normalize the overall spinal sagittal profile. Correction of Dub-LSA to above 90° might be used as an objective to better improve the sagittal alignment of the spine.

Significance of flexion range of motion as a risk factor for kyphotic change after cervical laminoplasty

Kyphotic deformity is a rare but serious complication after cervical laminoplasty (CLP), and several studies have investigated its predictors. In these studies, a kyphotic Cobb angle of 0°-5° between C2 and C7 at a certain postoperative time-point was often used to detect kyphotic deformity. However, studies considering the amount of cervical lordosis loss compared to the preoperative measurement are scarce. This study aimed to elucidate risk factors for kyphotic change after CLP by comparing patients with and without marked loss of cervical lordosis postoperatively. The study population was divided into seven patients with and 92 patients without a loss of >10° of the C2-7 angle during the follow-up period compared to the preoperative measurements [cervical lordosis loss (CLL) group and no CLL (NCLL) group, respectively]; demographic characteristics, surgical information, preoperative radiographic sagittal parameters of the cervical spine, and posterior paravertebral muscle morphology evaluated by magnetic resonance imaging were compared between two groups. A univariate analysis revealed that the CLL group had significantly greater flexion range of motion (fROM) than the NCLL group (43.0° vs. 25.8°, P < 0.001); however, no statistical significance was identified for other parameters. The fROM had a high capacity to discriminate between the CLL and NCLL groups (area under the receiver-operating characteristic curve, 0.880; P < 0.001; 95% confidence interval, 0.589-0.974) with an optimal cutoff point of 37°. This study suggests that greater fROM is a risk factor for the development of kyphotic changes after CLP. For patients with preoperative fROM exceeding 40°, CLP should be carefully indicated.

Predictive formula of cervical lordosis in asymptomatic young population

BACKGROUND

Not a large number of previous studies have reported the normal sagittal balance of the cervical spine and physiological cervical lordosis (CL) has not been clearly defined yet.

METHODS

This was a prospective radiological analysis of asymptomatic subjects. The following cervical sagittal parameters were measured: CL, thoracic inlet angle (TIA), T1 slope (T1S), neck tilt (NT), and C2-7 sagittal vertical axis (C2-7 SVA). The Pearson correlation test was calculated, and the stepwise multiple regression analysis was conducted by using the CL (dependent variable) and the other cervical sagittal parameters (independent variables) to determine the best sets of predictors. A paired sample t test was conducted between the predicted and measured values.

RESULTS

The mean age of 307 participants was 24.54 + 3.07. The mean CL, TIA, T1S, NT, and C2-C7 SVA was 17.11° ± 6.31°, 67.87° ± 7.78°, 25.84° ± 5.36°, 42.53° ± 6.68°, and 14.60 ± 8.20 mm, respectively. The formula was established as follows: CL = 0.762 × T1S - 0.392 × C2-C7 SVA + 0.25 × TIA - 13.795 (R = 0.812, R2 = 0.660) (stepwise multiple regression) and CL = 0.417 × TIA - 11.193 (R = 0.514, R2 = 0.264) (simple linear regression). There was no statistical difference between the predicted CL and the measured CL (t = 0.034, P = 0.973).

CONCLUSIONS

There was a significant correlation between CL and other cervical sagittal parameters, including TIA, T1S, NT, and C2-C7 SVA in asymptomatic Chinese population. The results of this study may serve as a normal reference value for the study of asymptomatic population.

Internal and external sagittal craniovertebral alignment: A comparison between radiological and photogrammetric approaches in asymptomatic participants

BACKGROUND

Photogrammetric measures are a commonly applied, highly reliable tool for appraising craniovertebral postures during clinical assessments, rehabilitation, and research interventions.

OBJECTIVE

This study aimed to compare and contrast three external measures of postural alignment (EMPA) using photogrammetric and radiological approaches, and to discuss whether the craniovertebral angle (CVA) reflects the shape of the underlying cervical spine.

DESIGN

Cross Sectional Correlation Study.

METHOD

Young adults attended three assessment sessions (S1, S2 and S3). S1 involved a standardised photogrammetric protocol. S2 involved radiographic image acquisition. S3 followed the same protocol in S1 but excluded the self-balancing procedure. Each session's EMPA were compared through either paired or independent samples t-tests. The different radiographic cervical subtypes and their corresponding CVAs were assessed.

RESULTS

There were no significant differences in any EMPA between the two photogrammetric sessions. The CVA was the only EMPA to show a significant difference between photogrammetric (S3) and radiographic approaches. Cervical subtype variability is present throughout the full CVA range.

CONCLUSIONS

Despite the statistically significant difference in the CVA between approaches, the mean difference was small and unlikely to be clinically meaningful. Accordingly, the quantification of EMPA can be undertaken with high levels of precision and reliability using standardised photogrammetric procedures. The CVA, however, does not provide an indication of the shape of the underlying cervical spine. The distinct radiological differences in the inter-segmental orientation of each vertebral motion segment in conjunction with the differences in the overall global cervical alignment, both within and between participants, negate this possibility.

The effect of cervical spine subtypes on center of pressure parameters in a large asymptomatic young adult population

BACKGROUND

Recent research highlighted that non-lordotic subtypes are common within an asymptomatic population of young adults. The potential mechanisms responsible for the decreased postural control witnessed in healthy participants exhibiting non-lordotic cervical alignment are unclear.

RESEARCH QUESTION

Therefore, the aim of this study is to compare and contrast asymptomatic radiographically derived sagittal cervical alignment subtypes with Center of Pressure (CoP) parameters.

METHODS

In this cross-sectional study strict asymptomatic inclusion criteria were met by 150 of the original 182 volunteers. All radiographs were assessed using a multi-method subtype system with participants classified into lordotic and non-lordotic groups. Participants performed 90s narrow stance trials with their eyes closed whilst standing on both a firm surface (FS) and compliant surface (CS) (3 trials per surface). CoP parameters were recorded from a force platform sampling at 100 Hz. Nonparametric statistical tests were conducted to assess differences between groups for each surface type and to determine differences in CoP parameters between FS and CS types.

RESULTS

Significant differences were found between groups on both surfaces for the anterior to posterior range (FS: p = 0.013; CS: p = 0.023), total excursion (FS: p = 0.029; CS: p = 0.005) and mean velocity of total excursion (FS: p = 0.032; CS: p = 0.004).

SIGNIFICANCE

Our data suggest that sagittal plane cervical alignment is a measure capable of distinguishing between the postural control of asymptomatic lordotic and non-lordotic young adult participants on both surfaces types. Furthermore, decreased postural control is present in asymptomatic participants across all non-lordotic subtypes and is not isolated exclusively to those with forward head posture. Consequently, future research endeavours should investigate the clinical significance of these non-lordotic findings in relation to both the potential for early cervical osseous degeneration and the transitional stages of non-specific pain sufferers from previously asymptomatic young adults.

Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial

Background

There is a growing interest concerning the understanding of and rehabilitation of the sagittal configuration of the cervical spine as a clinical outcome. However, the literature on the topic specific to conservative treatment outcomes of patients with chronic myofascial cervical pain syndrome (CMCPS) has not adequately addressed the relationship between cervical sagittal alignment and improved pain, disability and range of motion.

Methods

A randomized controlled study with a 1-year follow-up. Here, 120 (76 males) patients with chronic CMCPS and defined cervical sagittal posture abnormalities were randomly assigned to the control or an intervention group. Both groups received the Integrated neuromuscular inhibition technique (INIT); additionally, the intervention group received the denneroll cervical traction device. Alignment outcomes included two measures of sagittal posture: cervical angle (CV), and shoulder angle (SH). Patient relevant outcome measures included: neck pain intensity (NRS), neck disability (NDI), pressure pain thresholds (PPT), cervical range of motion using the CROM. Measures were assessed at three intervals: baseline, 10 weeks, and 1 year after the 10 week follow up.

Results

After 10 weeks of treatment, between group statistical analysis, showed equal improvements for both the intervention and control groups in NRS (p = 0.36) and NDI (p = 0.09). However, at 10 weeks, there were significant differences between groups favoring the intervention group for PPT (p<0.001) and all measures of CROM (p<0.001). Additionally, at 10 weeks the sagittal alignment variables showed significant differences favoring the intervention group for CV p<0.001 and SH (p<0.001) indicating improved CSA. Importantly, at the 1-year follow-up, between group analysis identified a regression back to baseline values for the control group for the non-significant group differences (NRS and NDI) at the 10-week mark. Thus, all variables were significantly different between groups favoring the intervention group at 1-year follow up: NRS (p<0.001), NDI (p<0.001), PPT p<0.001), CROM (p<0.001), CV (p<0.001), SH (p<0.001).

Conclusion

The addition of the denneroll cervical orthotic to a multimodal program positively affected CMCPS outcomes at long term follow up. We speculate the improved sagittal cervical posture alignment outcomes contributed to our findings.

Trial registration

Pan African Clinical Trial Registry Clinical Trial Registry: PACTR201801002968301, registered 11 January 2018 (retrospectively registered).

Cervical Spine Deformity-Part 3: Posterior Techniques, Clinical Outcome, and Complications

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications. Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

Alleviation of posttraumatic dizziness by restoration of the cervical lordosis: a CBP® case study with a one year follow-up

[Purpose] To present the successful treatment of posttraumatic dizziness and neck pains that were initiated in a patient following a whiplash event. [Subject and Methods] A 46 year old male suffered a whiplash event that initiated neck pain and dizziness symptoms. The patient had many positive orthopedic findings and demonstrated a forward head posture and cervical hypolordosis. The patient was treated by Chiropractic BioPhysics^® technique including cervical extension traction, extension exercises and spinal manipulative therapy initially three times a week for 16-weeks, and once a month thereafter. [Results] The patient had a resolution of daily dizziness and neck pain with a concomitant reduction of forward head translation and increase in cervical lordosis. The postural measures were further improved after one year of mostly home-care. [Conclusion] The cervical spine alignment may be an important biomarker for those with dizziness. The correction of cervical lordosis may be an essential requirement for superior clinical outcomes for those with posttraumatic dizziness.

Alleviation of neck pain by the non-surgical rehabilitation of a pathologic cervical kyphosis to a normal lordosis: a CBP® case report

[Purpose] To present a case of the therapeutic reversal of a cervical kyphosis into a lordosis in a patient who presented with neck pain and headaches. [Subject and Methods] A 24-year-old male irritated his neck while dancing. Upon examination it was revealed he had an excessive, 45 mm forward head translation and a 15° cervical kyphosis from C3-C6. The patient was treated with Chiropractic BioPhysics^® methods aimed at restoring the cervical lordosis by mirror image^®, neck extension exercises, cervical extension traction, and spinal manipulative therapy. [Results] After two weeks of treatments the patient reported a complete resolution of neck pain. After 24 treatments over 10-weeks, a lateral radiograph demonstrated the restoration of a cervical lordosis and a complete reduction of forward head translation. [Conclusion] This case demonstrates that a cervical kyphosis may be reversed into a lordosis in as little as 10-weeks by specific care incorporating cervical extension protocols. This case also supports the biomechanical literature that suggests those with cervical kyphosis may be predisposed to spinal injury. We suggest that correcting even asymptomatic patients with obvious cervical spine deformity should be accomplished prior to future injury and/or degenerative changes.

Cervical Spine Deformity-Part 2: Management Algorithm and Anterior Techniques

A sound operative plan based on solid understanding of the pathology and biomechanics is the most important part of cervical deformity correction. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In Part 2 of this three-part review series, we discuss the pre-operative planning, management algorithm, and anterior surgical techniques for cervical deformity correction.

Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification

Cervical spine deformities can have a significant negative impact on the quality of life by causing pain, myelopathy, radiculopathy, sensorimotor deficits, as well as inability to maintain horizontal gaze in severe cases. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and is often controversial. We aim to provide an overview of cervical spine deformity in a 3-part series covering topics including the biomechanics, radiographic parameters, classification, treatment algorithms, surgical techniques, clinical outcome, and complication avoidance with a review of pertinent literature.

The Effect of Technological Devices on Cervical Lordosis

PURPOSE:

There is a need for cervical flexion and even cervical hyperflexion for the use of technological devices, especially mobile phones. We investigated the effect of this use on the cervical lordosis angle.

MATERIAL AND METHODS:

A group of 156 patients who applied with only neck pain between 2013–2016 and had no additional problems were included. Patients are specifically questioned about mobile phone, tablet, and other devices usage. The value obtained by multiplying the year of usage and the average usage (hour) in daily life was determined as the total usage value (an average hour per day x year: hy). Cervical lordosis angles were statistically compared with the total time of use.

RESULTS:

In the general ROC analysis, the cut-off value was found to be 20.5 hy. When the cut-off value is tested, the overall accuracy is very good with 72.4%. The true estimate of true risk and non-risk is quite high. The ROC analysis is statistically significant.

CONCLUSION:

The use of computing devices, especially mobile telephones, and the increase in the flexion of the cervical spine indicate that cervical vertebral problems will increase even in younger people in future. Also, to using with attention at this point, ergonomic devices must also be developed.

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage

Background

Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients’ self-reported pain and functional disability, after ACDF with a PEEK cage.

Methods

We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients’ hospital discharge, and also at 6 and 12 months postoperatively.

Results

There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis.

Conclusions

In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients’ self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients’ own perceived recovery.

Preoperative cervical sagittal alignment parameters and their impacts on myelopathy in patients with cervical spondylotic myelopathy: a retrospective study

Background

Cervical sagittal alignment plays an important role in the pathogenesis of cervical spondylotic myelopathy (CSM), but there are limited studies on the cervical sagittal parameters in CSM patients and their correlations with myelopathy. The aim of this study is to investigate the correlations among the preoperative cervical sagittal alignment parameters and their correlations with the development of myelopathy in patients with CSM.

Methods

We retrospectively collected 212 patients with CSM who underwent surgical interventions. Gender, age, modified Japanese Orthopedic Association score (mJOA), cervical lordosis (CL), C2–C7 sagittal vertical axis (C2–C7 SVA), T1 slope (T1S), neck tilt (NT) and thoracic inlet angle (TIA) were collected before operation. Interobserver and intraobserver reliability were calculated for all measurements (intraclass correlation coefficient, ICC). Data were analyzed with Pearson and Spearman correlation tests and multiple linear regression analysis.

Results

A total of 212 patients with CSM were included in this study (male: 136, female: 76) with an average age of 54.5 ± 10.1 years old. Intraobserver and interobserver reliability for all included radiographic parameters presented good to excellent agreement (ICC > 0.7). No significant differences in demographic and radiological parameters have been observed between males and females (P > 0.05). We found statistically significant correlations among the following parameters: age with CL (r = 0.135, P = 0.049), age with T1S (r = 0.222, P = 0.001), CL with T1S (r = 0.291, P < 0.001), CL with C2-C7 SVA (r =  − 0.395, P < 0.001), mJOA with age (r =  − 0.274, P < 0.001), mJOA with C2–C7 SVA (r =  − 0.219, P < 0.001) and mJOA with T₁S(r =  − 0.171, p = 0.013). Linear regression analysis showed that C2–C7 SVA was the predictor of CL (adjusted R² = 0.152, P < 0.001) and multiple linear regression showed that age combined with C2–C7 SVA was a sensitive predictor of mJOA (adjusted R² = 0.106, P < 0.001).

Discussion

There were significant correlations among certain preoperative cervical sagittal parameters in CSM patients. CL was the only predictor of C2–C7 SVA. Age combined with C2–C7 SVA could predict the severity of myelopathy.

Effects of central and unilateral posteroanterior mobilization on cervical lordosis, muscle stiffness and ROM in patient with ankylosing spondylitis: case study

[Purpose] The aim of this study was to determine the effects of central and unilateral posteroanterior (PA) mobilization on cervical lordosis, muscle stiffness and range of motion in a patient with ankylosing spondylitis (AS). [Subject and Methods] The subject of this case study was diagnosed with AS in 1997. At baseline, variance was measured without any intervention during the first 3 days (2016.6.13-2016.6.15). Cervical PA mobilization was applied to each segment from C2-C7 from the 4th to the 11th day for 8 days. Intervention was not performed from the 12th to the 15th days for 4 days. Variances were measured a final time without intervention on the 16th day (2016.6.28). [Results] Cervical lordosis was seen to have increased. Muscle stiffness was significantly decreased after intervention and the effect of treatment lasted for five days without any additional intervention. The cervical flexion and extension angles were increased. However these increases were not statistically significant. Both the lateral flexion and left rotation angle were significantly increased and the effects of treatment lasted for five days without any additional intervention. [Conclusion] These results suggest that central and unilateral PA mobilization is effective in increasing cervical lordosis and range of motion, and decreasing muscle stiffness in patients with AS.

An in vitro evaluation of sagittal alignment in the cervical spine after insertion of supraphysiologic lordotic implants

PURPOSE

Cervical spine malalignment can develop as a consequence of degenerative disc disease or following spinal surgery. When normal sagittal alignment of the spine is disrupted, further degeneration may occur adjacent to the deformity. The purpose of this study was to investigate changes in lordosis and sagittal alignment in the cervical spine after insertion of supraphysiologic lordotic implants.

METHODS

Eight cadaveric cervical spines (Occiput-T1) were tested. The occiput was free to translate horizontally and vertically but constrained from angular rotation. The T1 vertebra was rigidly fixed with a T1 tilt of 23°. Implants with varying degrees of lordosis were inserted starting with single-level constructs (C5-C6), followed by two (C5-C7), and three-level (C4-C7) constructs. Changes in sagittal alignment, Occ-C2 angle, cervical lordosis (C2-7), and segmental lordosis were measured.

RESULTS

Increasing cage lordosis led to global increases in cervical lordosis. As implanted segmental lordosis increased, the axial levels compensated by decreasing in lordosis to maintain horizontal gaze. An increase in cage lordosis also corresponded with larger changes in SVA.

CONCLUSION

Reciprocal compensation was observed in the axial and sub-axial cervical spine, with the Occ-C2 segment undergoing the largest compensation. Adding more implant lordosis led to larger reciprocal changes and changes in SVA. Implants with supraphysiologic lordosis may allow for additional capabilities in correcting cervical sagittal plane deformity, following further clinical evaluation.

C7 sagittal vertical axis is the determinant of the C5-C7 angle in cervical sagittal alignment

BACKGROUND CONTEXT

Previous studies have indicated that the T1 slope correlates with cervical lordosis. In contrast, the specific impact of the C7 sagittal vertical axis (C7SVA) on cervical lordosis remains unknown.

PURPOSE

This study aimed to investigate the specific role of C7SVA in cervical lordosis.

STUDY DESIGN/SETTING

This was a retrospective radiographic study.

PATIENT SAMPLE

Forty-eight consecutive patients who underwent lateral standing radiography of the entire spine were retrospectively reviewed.

OUTCOME MEASURES

Radiographic parameters included occipito (Oc)-C7, Oc-C2, C2-C7, C2-C4, and C5-C7 angles; T1 slope; C7SVA; T1 pelvic angle (TPA); pelvic incidence; pelvic tilt; and sacral slope.

METHODS

The radiographs of 96 consecutive patients who underwent lateral standing radiography of the entire spine in June 2015 in our hospital were retrospectively reviewed. Patients having cervical deformities, having undergone cervical fusion, and under 18 years of age were excluded. A total of 48 Asian patients (14 men and 34 women; mean age, 54.6 years) were eligible. Pathologies included scoliosis, myelopathy, thoracolumbar deformity, and spondylosis. Spearman rank correlation coefficients were used to examine correlations between the parameters. The relationship between C5-C7 lordosis and the radiographic parameters was calculated using the forward stepwise multivariate regression analysis. The authors do not have financial associations relevant to this article.

RESULTS

C7SVA correlated with the Oc-C7 (r=0.42) and C2-C7 (r=0.50) angles. However, the correlation coefficient was smaller than that between the T1 slope and Oc-C7 (r=0.83) or C2-C7 (r=0.76) angles. When the C2-C7 angle was divided into C2-C4 and C5-C7 angles, C7SVA correlated with the C5-C7 (r=0.63) angle but not with the C2-C4 angle. The correlation coefficient between the C5-C7 angle and C7SVA was higher than that between the C5-C7 angle and T1 slope (r=0.53) or the C5-C7 angle and TPA (r=0.60). Using radiographic parameters and age, multiple regression analysis revealed that only C7SVA affected the C5-C7 angle.

CONCLUSIONS

C7SVA was the only radiographic parameter that affected the C5-C7 angle. Both T1 slope and C7SVA are key to the shape of the cervical sagittal alignment. The results of this study can be a starting point to improve our understanding of cervical sagittal alignment.

Influence of high-heeled shoes on the sagittal balance of the spine and the whole body

PURPOSE

Wearing high heels is associated with chronic pain of the neck, lower back and knees. The mechanisms behind this have not been fully understood. The purpose of this study was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels.

METHODS

Lateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups.

RESULTS

Standing in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p < 0.0001], and increased knee (Δ 2.4° ± 2.9°, p = 0.0009) and ankle flexion (Δ 38.7° ± 3.4°, p < 0.0001). The differences in C7 and meatus vertical axis, cervical and lumbar lordosis, thoracic kyphosis, spino-sacral angle, pelvic tilt, sacral slope, and spinal tilt were not significant. Individuals adapting with less-than-average knee flexion responded to high heels by an additional increase in cervical lordosis (Δ 5.8° ± 10.7° vs. 1.8° ± 5.3°).

CONCLUSIONS

In all participants, wearing high heels led to increased flexion of the knees and to more ankle flexion. While some participants responded to high heels primarily through the lower extremities, others used increased cervical lordosis to adapt to the shift of the body's center of gravity. This could explain the different patterns of pain in the neck, lower back and knees seen in individuals wearing high heels frequently.

Is more lordosis associated with improved outcomes in cervical laminectomy and fusion when baseline alignment is lordotic?

BACKGROUND CONTEXT

In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2-C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist.

PURPOSE

The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained.

STUDY DESIGN/SETTING

This is an analysis of a prospective surgical cohort at a single academic institution.

PATIENT SAMPLE

The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period.

OUTCOME MEASURES

The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1-C2 Cobb, C2-C7 Cobb, C1-C7 Cobb, C2-C7 SVA, C1-C7 SVA, and T1 slope.

METHODS

The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work.

RESULTS

There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2-C7 Cobb (mean change: +3.6°; p=.03) and C2-C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2-C7 SVA associated with worse SF-12 PCS scores (r=-0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs.

CONCLUSIONS

Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient.

Decreased neck muscle strength in patients with the loss of cervical lordosis

BACKGROUND

The loss of cervical lordosis is associated with some negative clinical outcomes. No previous study has examined cervical muscle strength, specifically in patients with the loss of cervical lordosis. This study aims to investigate whether there is weakness of the cervical muscles or an imbalance between cervical flexor and extensor muscle strength in patients with the loss of cervical lordosis compared with healthy controls matched by age, gender, body mass index (BMI), and employment status.

METHODS

Thirty-two patients with the loss of cervical lordosis (23 F, 9 M) and 31 healthy volunteers (23 F, 8 M) were included in the study. Maximal isometric neck extension and flexion strength, and the strength ratio between extension and flexion were used as evaluation parameters. All measurements were conducted by a blinded assessor using a digital force gauge. The participants were positioned on a chair in a neutral cervical position and without the trunk inclined during measurements.

FINDINGS

Maximal isometric neck extension and flexion strength values were significantly lower in the patients versus healthy controls (P<0.001 and P=0.040, respectively). The mean (SD) values of the extension/flexion ratio were 1.21 (0.34) in the patients and 1.46 ± 0.33 in the controls (P=0.004).

INTERPRETATION

According to our results, patients with the loss of cervical lordosis have reduced neck muscle strength, especially in the extensors. These findings may be beneficial for optimizing cervical exercise prescriptions.