Cervicothoracic Versus Proximal Thoracic Lower Instrumented Vertebra Have Comparable Radiographic and Clinical Outcomes in Adult Cervical Deformity

Abstract

Study Design: Comparative cohort study. Objective: Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear. Methods: A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared. Results: Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, P = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, P = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, P = 0.004). The PT group had a larger correction of cSVA (−7.7 vs 0.7 mm, P = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, P = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up. Conclusions: The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.

Optimizing Surgical Strategy for Cervical Spinal Deformity: Global Alignment and Surgical Targets

“…LIV selection is considered a key component in preventing DJK, aiming to avoid the curve’s apex [ 26 ]. However, the relationship between DJK and the LIV after cervical realignment surgery has received limited attention in the literature [ 22 , 23 , 27 ].…”

“…A study by Kim et al [ 27 ] compared CSD patients with LIV at the CTJ versus the proximal thoracic (PT) spine. The results revealed that patients with fusion to the PT spine demonstrated larger cSVA malalignment, greater T1S–CL mismatch, and a higher likelihood of requiring a pedicle subtraction osteotomy for correction.…”

“…26 However, the relationship between DJK and the LIV after cervical realignment surgery has received limited attention in the literature. 22,23,27 When performing multilevel cervical arthrodesis, spine surgeons often face the dilemma of whether to extend the fusion beyond the cervicothoracic junction (CTJ). 28,29 The advantage of not crossing the CTJ is preserving the physiological range of motion at the C7-T1 segment.…”