Reciprocal changes in cervical spine alignment after corrective thoracolumbar deformity surgery

Ha, Yoon; Schwab, Frank; Lafage, Virginie; Mundis, Gregory M.; Shaffrey, Christopher I.; Smith, Justin S.; Bess, Shay; Ames, Christopher P.

doi:10.1007/s00586-013-2953-8

Cited by 81 publications

(86 citation statements)

References 22 publications

(33 reference statements)

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“…49 Ha and colleagues subsequently confirmed this observation and further identified key radiographic parameters associated with these compensatory changes. 17 In addition, a high prevalence of concomitant CSD has been reported among adults with thoracolumbar deformity. 46 Collectively, these and other studies emphasize that assessment and classification of CSD should not occur in isolation and that alignment of the thoracolumbar spine and pelvis should also be assessed.…”

Section: Srs-schwab Classification Modifiermentioning

confidence: 99%

Reliability assessment of a novel cervical spine deformity classification system

Ames

Smith

Eastlack

et al. 2015

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OBJECT Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification. METHODS Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: “C,” “CT,” and “T” for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; “S” for primary coronal deformity with a coronal Cobb angle ≥ 15°; and “CVJ” for primary craniovertebral junction deformity. The modifiers included C2–7 sagittal vertical axis (SVA), horizontal gaze (chin-brow to vertical angle [CBVA]), T1 slope (TS) minus C2–7 lordosis (TS–CL), myelopathy (modified Japanese Orthopaedic Association [mJOA] scale score), and the Scoliosis Research Society (SRS)-Schwab classification for thoracolumbar deformity. Application of the classification system requires the following: 1) full-length standing posteroanterior (PA) and lateral spine radiographs that include the cervical spine and femoral heads; 2) standing PA and lateral cervical spine radiographs; 3) completed and scored mJOA questionnaire; and 4) a clinical photograph or radiograph that includes the skull for measurement of the CBVA. A series of 10 CSD cases, broadly representative of the classification system, were selected and sufficient radiographic and clinical history to enable classification were assembled. A panel of spinal deformity surgeons was queried to classify each case twice, with a minimum of 1 intervening week. Inter- and intrarater reliability measures were based on calculations of Fleiss k coefficient values. RESULTS Twenty spinal deformity surgeons participated in this study. Interrater reliability (Fleiss k coefficients) for the deformity descriptor rounds 1 and 2 were 0.489 and 0.280, respectively, and mean intrarater reliability was 0.584. For the modifiers, including the SRS-Schwab components, the interrater (round 1/round 2) and intrarater reliabilities (Fleiss k coefficients) were: C2–7 SVA (0.338/0.412, 0.584), horizontal gaze (0.779/0.430, 0.768), TS-CL (0.721/0.567, 0.720), myelopathy (0.602/0.477, 0.746), SRS-Schwab curve type (0.590/0.433, 0.564), pelvic incidence-lumbar lordosis (0.554/0.386, 0.826), pelvic tilt (0.714/0.627, 0.633), and C7-S1 SVA (0.071/0.064, 0.233), respectively. The parameter with the poorest reliability was the C7–S1 SVA, which may have resulted from differences in interpretation of positive and negative measurements. CONCLUSIONS The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.

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Section: Srs-schwab Classification Modifiermentioning

confidence: 99%

Reliability assessment of a novel cervical spine deformity classification system

Ames

Smith

Eastlack

et al. 2015

SPI

Self Cite

236

205

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“…Similarly, Lafage et al 18 reported a spontaneous increase in unfused TK following lumbar 3-column osteotomies. Lastly, both Smith et al 26 and Ha et al 14 reported spontaneous improvement of cervical alignment after correction of global sagittal malalignment following lumbar pedicle subtraction osteotomy. These studies focus on thoracolumbar deformities.…”

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confidence: 99%

“…1,14,16,26 The majority of literature regarding the management of ASD has focused on the thoracolumbar region with little regard for the adjacent regions. Several recent studies have demonstrated that regional spinal alignment and pathology can affect other spinal regions.…”

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confidence: 99%

Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients

Scheer

Passias

Sorocean

et al. 2016

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OBJECT A high prevalence of cervical deformity (CD) has been identified among adult patients with thoracolumbar spinal deformity undergoing surgical treatment. The clinical impact of this is uncertain. This study aimed to quantify the differences in patient-reported outcomes among patients with adult spinal deformity (ASD) based on presence of CD prior to treatment. METHODS A retrospective review was conducted of a multicenter prospective database of patients with ASD who underwent surgical treatment with 2-year follow-up. Patients were grouped by the presence of preoperative CD: 1) cervical positive sagittal malalignment (CPSM) C2–7 sagittal vertical axis ≥ 4 cm; 2) cervical kyphosis (CK) C2–7 angle > 0; 3) CPSM and CK (BOTH); and 4) no baseline CD (NONE). Health-related quality of life (HRQOL) scores included the Physical Component Summary and Mental Component Summary (PCS and MCS) scores of the 36-Item Short Form Health Survey (SF-36), Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22), and minimum clinically important difference (MCID) of these scores at 2 years. Standard radiographic measurements were conducted for cervical, thoracic, and thoracolumbar parameters. RESULTS One hundred eighty-two patients were included in this study: CPSM, 45; CK, 37; BOTH, 16; and NONE, 84. Patients with preoperative CD and those without had similar baseline thoracolumbar radiographic measurements and similar correction rates at 2 years. Patients with and without preoperative CD had similar baseline HRQOL and on average both groups experienced some HRQOL improvement. However, those with preoperative CPSM had significantly worse postoperative ODI, PCS, SRS-22 Activity, SRS-22 Appearance, SRS-22 Pain, SRS-22 Satisfaction, and SRS-22 Total score, and were less likely to meet MCID for ODI, PCS, SRS-22 Activity, and SRS-22 Pain scores with the following ORs and 95% CIs: ODI 0.19 (0.07–0.58), PCS 0.17 (0.06–0.47), SRS-22 Activity 0.23 (0.09–0.62), SRS-22 Pain 0.20 (0.08–0.53), and SRS-22 Appearance 0.34 (0.12–0.94). Preoperative CK did not have an effect on outcomes. Interestingly, despite correction of the thoracolumbar deformity, 53.3% and 51.4% of patients had persistent CPSM and persistent CK, respectively. CONCLUSIONS Patients with thoracolumbar deformity without preoperative CD are likely to have greater improvements in HRQOL after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity.

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“…Nine patients (18 %) were fused from the higher lumbar spine to the lower lumbar spine (4) or the sacrum (5), 26 (52 %) were fused from the lower thoracic to the lower lumbar spine (7) or the sacrum (19) and 15 patients (30 %) were fused from the higher thoracic to the lower lumbar spine (2) or the sacrum (13). The lower instrumented vertebra was L4 in 5 patients, L5 in 9 patients, and S1 in the remaining 41.…”

Section: Resultsmentioning

confidence: 99%

Variations of cervical lordosis and head alignment after pedicle subtraction osteotomy surgery for sagittal imbalance

et al. 2014

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Reciprocal changes in cervical spine alignment after corrective thoracolumbar deformity surgery

Abstract: In spinal deformity procedures, preoperative spinal alignment parameters, and surgical plans could affect postoperative cervical spine alignment.

Cited by 81 publications

References 22 publications

Reliability assessment of a novel cervical spine deformity classification system

Reliability assessment of a novel cervical spine deformity classification system

Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients

Variations of cervical lordosis and head alignment after pedicle subtraction osteotomy surgery for sagittal imbalance

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