A New Piece of the Puzzle to Understand Cervical Sagittal Alignment: Utilizing a Novel Angle δ to Describe the Relationship among T1 Vertebral Body Slope, Cervical Lordosis, and Cervical Sagittal Alignment

Neurosurgery 2019 DOI:10.1093/neuros/nyz088

Cervical alignment has become increasingly important in the planning of spine surgery. A relationship between the slope of T1 (T1S), the cervical lordosis (CL), and the overall cervical sagittal vertical axis (cSVA) has previously been demonstrated, but the exact nature of this relationship is poorly understood. In this study, we derive theoretical and empirical equations to better understand how T1S and CL affect cSVA. The first equation was developed on a theoretical basis using inherent trigonometric relationships of the cervical spine. By treating the cervical spine as the arc of a circumference, and by taking into account the cervical height (CH), the geometric relationship between theT1S, CL, and cSVA was described via a trigonometric identity utilizing a novel angle δ subtended by the CH and cSVA (δ = T1S-CL/2). The second equation was developed on an empiric basis by performing a multiple linear regression on data obtained from a retrospective review of a large multicenter deformity database. The theoretical equation determined that the value of cSVA could be expressed as: cSVA = CH ∗ tan(π/180 ∗ (T 1S −CL/2)) . The empirical equation determined that value of cSVA could be expressed as: cSVA = (1.1 ∗ T 1) −(0.43 ∗ CL) + 6.69. In both, the sagittal alignment of the head over the shoulders is directly proportional to the T1S and inversely proportional to CL/2. These 2 equations may allow surgeons to better understand how the CL compensates for the T1S, to accurately predict the postoperative cSVA, and to customize cervical interbody grafts by taking into consideration each individual patient’s specific cervical spine parameters.

Global Spinal Alignment in Cervical Kyphotic Deformity: The Importance of Head Position and Thoracolumbar Alignment in the Compensatory Mechanism

Neurosurgery 82:686–694, 2018

Previous studies have evaluated cervical kyphosis (C-kypho) using cervical curvature or chin-brow vertical angle, but the relationship between C-kypho and global spinal alignment is currently unknown.

OBJECTIVE: To elucidate global spinal alignment and compensatory mechanisms in primary symptomatic C-kypho using full-spine radiography.

METHODS: In this retrospectivemulticenter study, symptomatic primary C-kypho patients (Cerv group; n=103) and adult thoracolumbar deformity patients (TL group; n=119) were compared.We subanalyzed Cerv subgroups according to sagittal vertical axis (SVA) values of C7 (SVAC7 positive or negative [C7P or C7N]). Various Cobb angles (◦) and SVAs (mm) were evaluated.

RESULTS: SVAC7 values were –20.2 and 63.6 mm in the Cerv group and TL group, respectively (P < .0001). Various statistically significant compensatory curvatures were observed in the Cerv group, namely larger lumbar lordosis (LL) and thoracic kyphosis. The C7N group had significantly lower SVACOG (center of gravity of the head) and SVAC7 (32.9 and –49.5 mm) values than the C7P group (115.9 and 45.1 mm). Sagittal curvatures were also different in T4-12, T10-L2, LL4-S, and LL. The value of pelvic incidence (PI)-LL was different (C7N vs C7P; –2.2◦ vs 9.9◦; P < .0003). Compensatory sagittal curvatures were associated with potential for shifting of SVAC7 posteriorly to adjust head position. PI-LL affected these compensatory mechanisms. CONCLUSION: Compensation in symptomatic primary C-kypho was via posterior shifting of SVAC7, small T1 slope, and large LL. However, even in C-kypho patients, lumbar degeneration might affect global spinal alignment. Thus, global spinal alignment with cervical kyphosis is characterized as head balanced or trunk balanced.

Outpatient Anterior Cervical Discectomy and Fusion: Indications and Clinical Experience in a Consecutive Series of 390 Patients

Neurosurg Q 2010;20:107–110

Objective: To assess the safety and efficacy of outpatient anterior cervical discectomy and fusion (ACDF) carried out on outpatients.

Methods: We retrospectively reviewed the records of 390 consecutive patients who underwent outpatient ACDF between September 2002 and September 2007 to assess the safety and efficacy of outpatient anterior cervical surgery. The mean age of the patient sample was 46; 56% were female and 44% were male. Indications for surgery consisted of cervical radiculopathy or myelopathy. Charts were reviewed to define patient demographics and medical comorbidities. Operative data, including levels treated, surgery time, time to discharge, and intraoperative complications were collected. Clinical outcomes were collected using the PhDx Clinical Outcomes Database. Need for hospital transfer from the ambulatory surgical center, emergency room visits, and subsequent hospital admission in the perioperative period were determined from patient records. Complications, patient satisfaction, and outcome were ascertained through review of notes from the first postoperative visit.

Results: There was no mortality and there were no major complications. Out of 390 patients, operation was carried out at 1 level in 223 patients, at 2 levels in 143, and at 3 levels in 24. Pain was present in 99%, motor deficit in 31%, and myelopathy in 14%. Twenty-five percent were hypertensive, 5% were diabetic, and 2% had coronary artery disease. The incidence of hospital transfer for ACDF related complications was <1%, emergency room visits <1% and subsequent hospitalization <1%. At the time of the first postoperative visit 92% of patients believed that they were improved and only 1% of patients had transiently increased radicular weakness.

Conclusion: Outpatient ACDF is safe and efficacious in selected patients.