Themistocles S Protopsaltis1, Subaraman Ramchandran1, D Kojo Hamilton2, Daniel Sciubba3, Peter G Passias1, Virginie Lafage4, Renaud Lafage4, Justin S Smith5, Robert A Hart6, Munish Gupta7, Douglas Burton8, Shay Bess9, Christopher Shaffrey5, Christopher P Ames10. 1. Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, New York, NY. 2. Department of Neurosurgery, University of Pittsburg Medical Center, Pittsburgh, PA. 3. Department of Orthopedic Surgery, Johns Hopkins University Medical Center, Baltimore MD. 4. Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY. 5. Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA. 6. Swedish Neuroscience Institute, Seattle, WA. 7. Department of Orthopedic Surgery, Washington University Medical Center, St. Louis, MO. 8. Department of Orthopedic Surgery, Kansas University Hospital, Kansas City, KS. 9. Department of Orthopaedic Surgery, Denver International Spine Clinic, Denver, CO. 10. Department of Neurosurgery, University of California San Francisco, San Francisco, CA.
Abstract
STUDY DESIGN: Prospective multicenter cohort study with consecutive enrollment. OBJECTIVE: To evaluate preoperative alignment and surgical factors associated with suboptimal early postoperative radiographic outcomes after surgery for cervical deformity. SUMMARY OF BACKGROUND DATA: Recent studies have demonstrated correlation between cervical sagittal alignment and patient-reported outcomes. Few studies have explored cervical deformity correction prospectively, and the factors that result in successful versus failed cervical alignment corrections remain unclear. METHODS: Patients with adult cervical deformity (ACD) included with either cervical kyphosis more than 10°, C2-C7 sagittal vertical axis (cSVA) of more than 4 cm, or chin-brow vertical angle of more than 25°. Patients were categorized into failed outcomes group if cSVA of more than 4 cm or T1 slope and cervical lordosis (TS-CL) of more than 20° at 6 months postoperatively. RESULTS: A total of 71 patients with ACD (mean age 62 yr, 56% women, 41% revisions) were included. Fourty-five had primary cervical deformities and 26 at the cervico-thoracic junction. Thirty-three (46.4%) had failed radiographic outcomes by cSVA and 46 (64.7%) by TS-CL. Failure to restore cSVA was associated with worse preoperative C2 pelvic tilt angle (CPT: 64.4° vs. 47.8°, P = 0.01), worse postoperative C2 slope (35.0° vs. 23.8°, P = 0.004), TS-CL (35.2° vs. 24.9°, P = 0.01), CPT (47.9° vs. 28.2°, P < 0.001), "+" Schwab modifiers (P = 0.007), revision surgery (P = 0.05), and failure to address the secondary, thoracolumbar driver of the deformity (P = 0.02). Failure to correct TS-CL was associated with worse preoperative cervical kyphosis (10.4° vs. -2.1°, P = 0.03), CPT (52.6° vs. 39.1°, P = 0.04), worse postoperative C2 slope (30.2° vs. 13.3°, P < 0.001), cervical lordosis (-3.6° vs. -15.1°, P = 0.01), and CPT (37.7° vs. 24.0°, P < 0.001). Multivariate analysis revealed postoperative distal junctional kyphosis associated with suboptimal outcomes by cSVA (odds ratio 0.06, confidence interval 0.01-0.4, P = 0.004) and TS-CL (odds ratio 0.15, confidence interval 0.02-0.97, P = 0.05). CONCLUSION: Factors associated with failure to correct the cSVA included revision surgery, worse preoperative CPT, and concurrent thoracolumbar deformity. Failure to correct the TS-CL mismatch was associated with worse preoperative cervical kyphosis and CPT. Occurrence of early postoperative distal junctional kyphosis significantly affects postoperative radiographic outcomes. LEVEL OF EVIDENCE: 3.
STUDY DESIGN: Prospective multicenter cohort study with consecutive enrollment. OBJECTIVE: To evaluate preoperative alignment and surgical factors associated with suboptimal early postoperative radiographic outcomes after surgery for cervical deformity. SUMMARY OF BACKGROUND DATA: Recent studies have demonstrated correlation between cervical sagittal alignment and patient-reported outcomes. Few studies have explored cervical deformity correction prospectively, and the factors that result in successful versus failed cervical alignment corrections remain unclear. METHODS:Patients with adult cervical deformity (ACD) included with either cervical kyphosis more than 10°, C2-C7 sagittal vertical axis (cSVA) of more than 4 cm, or chin-brow vertical angle of more than 25°. Patients were categorized into failed outcomes group if cSVA of more than 4 cm or T1 slope and cervical lordosis (TS-CL) of more than 20° at 6 months postoperatively. RESULTS: A total of 71 patients with ACD (mean age 62 yr, 56% women, 41% revisions) were included. Fourty-five had primary cervical deformities and 26 at the cervico-thoracic junction. Thirty-three (46.4%) had failed radiographic outcomes by cSVA and 46 (64.7%) by TS-CL. Failure to restore cSVA was associated with worse preoperative C2 pelvic tilt angle (CPT: 64.4° vs. 47.8°, P = 0.01), worse postoperative C2 slope (35.0° vs. 23.8°, P = 0.004), TS-CL (35.2° vs. 24.9°, P = 0.01), CPT (47.9° vs. 28.2°, P < 0.001), "+" Schwab modifiers (P = 0.007), revision surgery (P = 0.05), and failure to address the secondary, thoracolumbar driver of the deformity (P = 0.02). Failure to correct TS-CL was associated with worse preoperative cervical kyphosis (10.4° vs. -2.1°, P = 0.03), CPT (52.6° vs. 39.1°, P = 0.04), worse postoperative C2 slope (30.2° vs. 13.3°, P < 0.001), cervical lordosis (-3.6° vs. -15.1°, P = 0.01), and CPT (37.7° vs. 24.0°, P < 0.001). Multivariate analysis revealed postoperative distal junctional kyphosis associated with suboptimal outcomes by cSVA (odds ratio 0.06, confidence interval 0.01-0.4, P = 0.004) and TS-CL (odds ratio 0.15, confidence interval 0.02-0.97, P = 0.05). CONCLUSION: Factors associated with failure to correct the cSVA included revision surgery, worse preoperative CPT, and concurrent thoracolumbar deformity. Failure to correct the TS-CL mismatch was associated with worse preoperative cervical kyphosis and CPT. Occurrence of early postoperative distal junctional kyphosis significantly affects postoperative radiographic outcomes. LEVEL OF EVIDENCE: 3.
Authors: H Koller; C Ames; H Mehdian; R Bartels; R Ferch; V Deriven; H Toyone; C Shaffrey; J Smith; W Hitzl; J Schröder; Yohan Robinson Journal: Eur Spine J Date: 2018-11-27 Impact factor: 3.134
Authors: Alexander B Dru; Dennis Timothy Lockney; Sasha Vaziri; Matthew Decker; Adam J Polifka; W Christopher Fox; Daniel J Hoh Journal: Neurospine Date: 2019-09-30
Authors: Peter Gust Passias; Samantha R Horn; Virginie Lafage; Renaud Lafage; Justin S Smith; Breton G Line; Themistocles S Protopsaltis; Alex Soroceanu; Cole Bortz; Frank A Segreto; Waleed Ahmad; Sara Naessig; Katherine E Pierce; Avery E Brown; Haddy Alas; Han Jo Kim; Alan H Daniels; Eric O Klineberg; Douglas C Burton; Robert A Hart; Frank J Schwab; Shay Bess; Christopher I Shaffrey; Christopher P Ames Journal: J Craniovertebr Junction Spine Date: 2021-03-04
Authors: Katherine E Pierce; Peter Gust Passias; Avery E Brown; Cole A Bortz; Haddy Alas; Renaud Lafage; Oscar Krol; Dean Chou; Douglas C Burton; Breton Line; Eric Klineberg; Robert Hart; Jeffrey Gum; Alan Daniels; Kojo Hamilton; Shay Bess; Themistocles Protopsaltis; Christopher Shaffrey; Frank A Schwab; Justin S Smith; Virginie Lafage; Christopher Ames Journal: J Craniovertebr Junction Spine Date: 2021-09-08
Authors: Peter Gust Passias; Haddy Alas; Katherine E Pierce; Matthew Galetta; Oscar Krol; Lara Passfall; Nicholas Kummer; Sara Naessig; Waleed Ahmad; Bassel G Diebo; Renaud Lafage; Virginie Lafage Journal: J Craniovertebr Junction Spine Date: 2021-09-08