The Association of Cervical Spine Alignment with Neurologic Recovery in a Prospective Cohort of Patients with Surgical Myelopathy: Analysis of a Series of 124 Cases

Shamji, Mohammed F.; Mohanty, Chandan; Massicotte, Eric M.; Fehlings, Michael G.

doi:10.1016/j.wneu.2015.09.044

Cited by 70 publications

(45 citation statements)

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“…[3,8,27–30] In our series, patients with a shorter duration of symptoms or better functional status at presentation with less compression of the cord had greater neurological improvement after surgery.…”

Section: Discussionmentioning

confidence: 90%

Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy

Kim

Ha²,

Shin

et al. 2016

Medicine

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Section: Discussionmentioning

confidence: 90%

Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy

Kim

Ha²,

Shin

et al. 2016

Medicine

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“…Furthermore cervical sagittal balance before and after surgery appears to have a major influence on the clinical course of patients [1, 11–15]. Cervical alignment can be measured locally by Cobb angle, which is still the most commonly used local measurement method due to its validity.…”

Section: Introductionmentioning

confidence: 99%

The influence of sagittal profile alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A Delta-Omega-analysis

Koeppen¹,

Piepenbrock²,

Kroppenstedt³

et al. 2017

PLoS ONE

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PurposeDecompression and maintaining or restoring a cervical lordosis are major goals in the surgical treatment of cervical spondylotic myelopathy (CSM). Numerous studies support the assumption that cervical lordosis is a key factor for neurological recovery and pain reduction. However, even kyphotic patients can be asymptomatic. The balance of the spine is subject of an increasing number of publications. The main purpose of the study was to evaluate the validity of lordotic alignment on the course of CSM and to set this parameter in context with well-validated tools, namely the modified Japanese Orthopaedic Association scoring system (mJOAS) and the visual analogue scale (VAS), to predict and measure the clinical outcome after surgery.MethodsThis is a retrospective study with prospectively collected data of a heterogeneous cohort. The authors analyzed the records of 102 patients suffering from CSM that underwent decompressive surgery and instrumentation. Clinical outcome was assessed by using the mJOAS, VAS and Odom’s criteria. The radiological analysis involved comparison of pre- and postoperative radiographs. The patients were divided into subgroups to be able to compare the influence of various amounts of correction (3 Delta-groups: <0°, 1–7° and ≥8°) and final lordosis (4 Omega-groups: 0–7°, 8–14°, 15–21°, ≥22°).Results219 levels were fused in 102 patients. Surgery improved the clinical outcome of all groups significantly. A lordotic profile was achieved in all analyzed groups. Patients that showed small lordosis after surgery (<8°) did not have an inferior clinical outcome compared to patients with larger cervical lordosis (>14°). The comparison of Odom’s criteria showed that preoperatively kyphotic patients benefitted more from surgery than lordotic patients (p = 0.029), but no differences could be seen comparing neck pain and neurological improvement. The improvement of pain and neurological impairment measured by VAS and mJOAS supports the statistical impact and validity of the data despite comparatively small numbers of patients. The lack of postoperative kyphosis is a major limitation of the study to encompass the impact of sagittal alignment on clinical outcome.ConclusionsDecompression and stabilization appear to be key elements of surgical treatment of CSM. While the achievement of cervical lordosis remains a major goal of surgery, clinical improvement is not hindered in patients who show small lordosis. However, kyphosis should be eliminated in symptomatic patients. The terms “balance” and “physiologic lordosis” remain complex entities without clear definition. To check the results of our study controlled randomized trials to validate and determine the exact role of cervical balance on the course of CSM would be helpful.

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“…19 It is one of the critical factors that influence the decision for either an anterior or a posterior approach. Furthermore, lordosis is the natural shape, and the restoration of lordosis is a goal of most surgeries.…”

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confidence: 99%

“…Indeed, increasing evidence suggests that neurological outcomes, quality of life, and the rate of adjacent-segment degeneration are optimized with establishment of cervical lordosis. 9,19 Recently, more attention has been paid to global spinal balance.6,7 Parameters like T-1 slope and sagittal vertical axis (SVA) have been introduced. These and other parameters are quantified in angles and distance (in mil- OBJECTIVE Although there is increasing recognition of the importance of cervical spinal sagittal balance, there is a lack of consensus as to the optimal method to accurately assess the cervical sagittal alignment.…”

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confidence: 99%

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An assessment of the most reliable method to estimate the sagittal alignment of the cervical spine: analysis of a prospective cohort of 138 cases

Donk¹,

Fehlings

Verhagen

et al. 2017

Journal of Neurosurgery: Spine

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OBJECTIVEAlthough there is increasing recognition of the importance of cervical spinal sagittal balance, there is a lack of consensus as to the optimal method to accurately assess the cervical sagittal alignment. Cervical alignment is important for surgical decision making. Sagittal balance of the cervical spine is generally assessed using one of two methods; namely, measuring the angle between C-2 and C-7, and drawing a line between C-2 and C-7. Here, the best method to assess sagittal alignment of the cervical spine is investigated.METHODSData from 138 patients enrolled in a randomized controlled trial (Procon) were analyzed. Two investigators independently measured the angle between C-2 and C-7 by using Harrison's posterior tangent method, and also estimated the shape of the sagittal curve by using a modified Toyama method. The mean angles of each quantitative assessment of the sagittal alignment were calculated and the results were compared. The interrater reliability for both methods was estimated using Cronbach's alpha.RESULTSFor both methods the interrater reliability was high: for the posterior tangent method it was 0.907 and for the modified Toyama technique it was 0.984. For a lordotic cervical spine, defined by the modified Toyama method, the mean angle (defined by Harrison's posterior tangent method) was 23.4° ± 9.9° (range 0.4°–52.4°), for a kyphotic cervical spine it was −2.2° ± 9.2° (range −16.1° to 16.9°), and for a straight cervical spine it was 10.5° ± 8.2° (range −11° to 36°).CONCLUSIONSAn absolute measurement of the angle between C-2 and C-7 does not unequivocally define the sagittal cervical alignment. As can be seen from the minimum and maximum values, even a positive angle between C-2 and C-7 could be present in a kyphotic spine. For this purpose, the modified Toyama method (drawing a line from the posterior inferior part of the vertebral body of C-2 to the posterior upper part of the vertebral body of C-7 without any measurements) is a better tool for a global assessment of cervical sagittal alignment.Clinical trial registration no.: ISRCTN41681847 (https://www.isrctn.com)

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The Association of Cervical Spine Alignment with Neurologic Recovery in a Prospective Cohort of Patients with Surgical Myelopathy: Analysis of a Series of 124 Cases

Cited by 70 publications

References 20 publications

Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy

Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy

The influence of sagittal profile alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A Delta-Omega-analysis

An assessment of the most reliable method to estimate the sagittal alignment of the cervical spine: analysis of a prospective cohort of 138 cases

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