Tag: kyphosis

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The gap between surgeon goal and achieved sagittal alignment in adult cervical spine deformity surgery

J Neurosurg Spine 42:309–319, 2025

This study assessed surgeons’ ability to achieve preoperative sagittal alignment goals in adult cervical spine deformity surgeries. Results showed significant deviations from targets, especially in severe deformities, highlighting the need for improved surgical planning and personalized implants.

Study Overview

• Objective: Assess surgeons’ ability to achieve preoperative sagittal alignment goals in CSD surgery.

• Methods: Prospective study with adult CSD patients across 13 North American centers.

• Patient Demographics: Mean age 63.6 years; 51.1% women; 38.6% had previous cervical fusion.

Key Findings

• Alignment Goals: Surgeons failed to meet goals by 17.2 mm for C2–7 SVA, 10.3° for Cobb angle.

• Factors Affecting Outcomes: Greater baseline TK linked to better Cobb angle achievement.

• Surgical Planning: 60% used PACS, 33.3% used spine-specific software.

• Tools and Criteria: Ames/ISSG criteria used by 33.3% of surgeons; others individualized goals.

Challenges and Recommendations

• Severe Deformities: More challenging to achieve alignment goals in severe cases.

• Need for Advancements: Personalized implants could improve intraoperative goal achievement.

• Alignment Correlations: Strong correlation for C7–S1 SVA, weak for C2–7 SVA.

Statistical Analysis

• Offset Groups: Patients categorized by offset magnitude from goal alignment.

• Significant Associations: Lower baseline TS-CL associated with better TS-CL goal achievement.

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Is multilevel MIS-TLIF with bilateral facetectomy a lordosing procedure?

J Neurosurg Spine 42:158–168, 2025

• Objective: The study aimed to evaluate the outcomes of 3-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and its effect on sagittal balance, particularly in patients with different preoperative segmental lordosis (SL) values.

• Methods: A retrospective analysis of 47 patients who underwent 3-level MIS-TLIF was conducted, with a focus on radiological and clinical outcomes.

• Surgical Techniques: The procedure involved using bullet-shaped static polyetheretherketone cages filled with autologous bone graft and demineralized bone matrix (DBM).

• Results: Patients with a preoperative SL ≤ 27° showed significant improvements in spinopelvic parameters, while those with SL > 27° had insignificant changes.

• Clinical Outcomes: All patients reported clinical improvements, as evidenced by the Oswestry Disability Index and visual analog scale scores.

• Conclusions: The study concluded that 3-level MIS-TLIF can effectively improve sagittal balance, especially in patients with a smaller preoperative lordotic curve.

• Implications: The findings suggest that MIS-TLIF is beneficial for restoring lumbar alignment and improving clinical outcomes in specific patient groups.

• Limitations: The study’s limitations include a small sample size and lack of a control group, which may affect the generalizability of the results.

 

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Incidence and Risk Factor of Implant Dislocation After Cervical Disk Arthroplasty: A Retrospective Cohort Analysis of 756 Patients

Neurosurgery 93:330–338, 2023

Implant dislocation after cervical disk arthroplasty (CDA) is obviously a critical complication, but no information about the incidence and associated risk factor has been reported.

OBJECTIVE: To investigate the incidence and risk factor of implant dislocation after CDA by a retrospective cohort analysis.

METHODS: A retrospective review of a consecutive series of CDA performed between January 2009 and March 2021 at a single institution was conducted. Analyses of chart records and radiological data established the incidence and associated risk factor of implant dislocation after CDA. A Kaplan-Meier survival estimation of implant survival was performed.

RESULTS: A total of 756 consecutive patients were included in this analysis. Five patients (0.7%) had a migration and even dropout of the artificial disk. The overall cumulative survival rate of the implant reached approximately 99.3% of the 756 patients. Preoperative kyphosis was significantly related to implant dislocation (P = .016), with an odds ratio of 15.013.

CONCLUSION: The incidence of implant dislocation after CDA is as low as 0.7% or 5/756 patients. Preoperative kyphosis significantly increases the risk of postoperative implant dislocation by a factor of 15. The migrating implants could be revealed on radiographs as early as 0.9 to 1.4 months postoperatively and were revised to anterior cervical diskectomy and fusion within half a year. No new event of implant dislocation occurred half a year postoperatively. The overall cumulative survival rate of the implant reached 99.3% of the 756 patients. In conclusion, CDA remains a safe and reliable procedure.

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Spinopelvic sagittal compensation in adult cervical deformity

J Neurosurg Spine 39:1–10, 2023

The objective of this study was to evaluate spinopelvic sagittal alignment and spinal compensatory changes in adult cervical kyphotic deformity.

METHODS A database composed of 13 US spine centers was retrospectively reviewed for adult patients who underwent cervical reconstruction with radiographic evidence of cervical kyphotic deformity: C2–7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, or cervical kyphosis (T1 slope [T1S] cervical lordosis [CL] > 15°) (n = 129). Sagittal parameters were evaluated preoperatively and in the early postoperative window (6 weeks to 6 months postoperatively) and compared with asymptomatic control patients. Adult cervical deformity patients were further stratified by degree of cervical kyphosis (severe kyphosis, C2–T3 Cobb angle ≤ −30°; moderate kyphosis, ≤ 0°; and minimal kyphosis, > 0°) and severity of sagittal malalignment (severe malalignment, sagittal vertical axis T3–S1 ≤ −60 mm; moderate malalignment, ≤ 20 mm; and minimal malalignment > 20 mm).

RESULTS Compared with asymptomatic control patients, cervical deformity was associated with increased C0–2 lordosis (32.9° vs 23.6°), T1S (33.5° vs 28.0°), thoracolumbar junction kyphosis (T10–L2 Cobb angle −7.0° vs −1.7°), and pelvic tilt (PT) (19.7° vs 15.9°) (p < 0.01). Cervicothoracic kyphosis was correlated with C0–2 lordosis (R = −0.57, p < 0.01) and lumbar lordosis (LL) (R = −0.20, p = 0.03). Cervical reconstruction resulted in decreased C0–2 lordosis, increased T1S, and increased thoracic and thoracolumbar junction kyphosis (p < 0.01). Patients with severe cervical kyphosis (n = 34) had greater C0–2 lordosis (p < 0.01) and postoperative reduction of C0–2 lordosis (p = 0.02) but no difference in PT. Severe cervical kyphosis was also associated with a greater increase in thoracic and thoracolumbar junction kyphosis postoperatively (p = 0.01). Patients with severe sagittal malalignment (n = 52) had decreased PT (p = 0.01) and increased LL (p < 0.01), as well as a greater postoperative reduction in LL (p < 0.01).

CONCLUSIONS Adult cervical deformity is associated with upper cervical hyperlordotic compensation and thoracic hypokyphosis. In the setting of increased kyphotic deformity and sagittal malalignment, thoracolumbar junction kyphosis and lumbar hyperlordosis develop to restore normal center of gravity. There was no consistent compensatory pelvic retroversion or anteversion among the adult cervical deformity patients in this cohort.

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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.

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A Prospective Study of Interbody Fat Graft ApplicationWith the Anterior Contralateral Cervical Microdiscectomy to Preserve Segmental Mobility

Neurosurgery 81:627–637, 2017

Any surgical procedure aims at protecting mobile segments at the operated level, and the sagittal balance of the columna vertebralis. Interbody fusion has become an often applied technique in anterior cervical discectomy.

OBJECTIVE: To indicate that a minimally invasive technique in which we use interbody fat graft placement showed great results and effectiveness, especially in patients who were suffering from cervical paramedian disc herniation.

METHODS: In this study, 432 patients were observed from 2000 to 2013. All these consecutive patients had paramedian disc herniation. The initial 239 patients (group 1) underwent microdiscectomy without graft placement, whereas the remaining 193 patients (group 2) had a microdiscectomy with interbody fat graft insertion. The Neck Disability Index (NDI) and Short Form-36 (SF-36)were used to evaluate clinical outcomes. Theywere followed up for 5.3 years (range 2-13 years).

RESULTS: Spontaneous radiological fusionwas noticed in 12%of group 1 patients and none of the group 2 patients. It has been observed that the mean overall cervical curvature (C2- 7) angles and segmental lordosis did not change significantly in late follow-up findings. During both early and late follow-ups, all patients indicated a decreasing NDI score, but in late follow-up, an improving SF-36 score.

CONCLUSION: This surgical technique provides good direct decompression and preserves mobility at the treated level, while preventing disc collapse.

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Evolution of Sagittal Imbalance Following Corrective Surgery for Sagittal Plane Deformity

Neurosurgery 81:129–134, 2017

Sagittal balance in adult spinal deformity is a major predictor of quality of life. A temporary loss of paraspinalmuscle force and somatic pain following spine surgery may limit a patient’s ability to maintain posture.

OBJECTIVE: To assess the evolution of sagittal balance and clinical outcomes during recovery from adult spinal deformity surgery.

METHODS: Retrospective review of a prospective observational database identified a consecutive series of patients with sagittal vertical axis (SVA) > 40mm undergoing adult deformity surgery. Radiographic parameters and clinical outcomes were measured out to 2 yr after surgery.

RESULTS: A total of 113 consecutive patients met inclusion criteria. Mean preoperative SVA was 90.3 mm, increased to 104.6mm in the first week, then gradually reduced at each follow-up interval to 59.2mm at 6wk, 45.0mm at 3mo, 38.6mm at 6mo, and 34.1mm at 1 yr (all P < .05). SVA did not change between 1 and 2 yr. Pelvic incidence-lumbar lordosis (PI-LL) corrected immediately from 25.3◦ to 8.5◦ (16.8◦ change; P < .01) and a decreased pelvic tilt from 27.6◦ to 17.6◦ (10◦ change; P < .01). No further change was noted in PILL. Pelvic tilt increased to 20.2◦ (P = .01) at 6wk and held steady through 2 yr. Mean Visual Analog Scale, Oswestry Disability Index, and Short Form-36 scores all improved; pain rapidly improved, whereas disability measures improved as SVA improved.

CONCLUSION: Radiographic assessment of global sagittal alignment did not fully reflect surgical correction of sagittal balance until 6 months after adult deformity surgery. Sagittal balance initially worsened then steadily improved at each interval over the first year postoperatively. At 1 yr, all clinical and radiographic measures outcomes were significantly improved.

 

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Greenstick fracture technique to correct kyphosis

Although posterior decompressive surgery is widely used to treat patients with cervical myelopathy and multilevel ossification of the posterior longitudinal ligament (OPLL), a poor outcome is anticipated if the sagittal alignment is kyphotic (or K-line negative). Accordingly, it is mandatory to perform anterior decompression and fusion in patients with cervical kyphosis. However, it can be difficult to perform anterior surgery because of the high risk of complications. This present report proposes a novel “greenstick fracture technique” to change the K-line from negative to positive in patients with cervical myelopathy, OPLL, and kyphotic deformity.

METHODS Four patients with cervical myelopathy, continuous-type OPLL, and kyphotic sagittal alignment (who were K-line negative) were indicated for surgery. Posterior laminectomy and lateral mass screw insertions using a posterior approach were performed, followed by anterior surgery. Multilevel discectomy and thinning of the OPLL mass by bur drilling was performed, then an intentional greenstick fracture at each disc level was made to convert the cervical K-line from negative to positive. Finally, posterior instrumentation using a rod was carried out to maintain cervical lordosis.

RESULTS MRI showed complete decompression of the cord by posterior migration in all cases, which had been caused by cervical lordosis. Restoration of neurological defects was confirmed at the 1-year follow-up assessment. No specific complications were identified that were associated with this technique.

CONCLUSIONS A greenstick fracture technique may be effective and safe when applied to patients with cervical myelopathy, continuous-type OPLL, and kyphotic deformity (K-line negative). However, further studies with more cases will be required to reveal its generalizability and safety.

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Complication Rates Associated With Adult Cervical Deformity Surgery

prospective-multicenter-assessment-of-early-complication-rates-associated-with-adult-cervical-deformity-surgery-in-78-patients

Neurosurgery 79:378–388, 2016

Few reports have focused on treatment of adult cervical deformity (ACD).

OBJECTIVE: To present early complication rates associated with ACD surgery.

METHODS: A prospective multicenter database of consecutive operative ACD patients was reviewed for early (#30 days from surgery) complications. Enrollment required at least 1 of the following: cervical kyphosis .10 degrees, cervical scoliosis .10 degrees, C2-7 sagittal vertical axis .4 cm, or chin-brow vertical angle .25 degrees.

RESULTS: Seventy-eight patients underwent surgical treatment for ACD (mean age, 60.8 years). Surgical approaches included anterior-only (14%), posterior-only (49%), anterior-posterior (35%), and posterior-anterior-posterior (3%). Mean numbers of fused anterior and posterior vertebral levels were 4.7 and 9.4, respectively. A total of 52 early complications were reported, including 26 minor and 26 major. Twenty-two (28.2%) patients had at least 1 minor complication, and 19 (24.4%) had at least 1 major complication. Overall, 34 (43.6%) patients had at least 1 complication. The most common complications included dysphagia (11.5%), deep wound infection (6.4%), new C5 motor deficit (6.4%), and respiratory failure (5.1%). One (1.3%) mortality occurred. Early complication rates differed significantly by surgical approach: anterior-only (27.3%), posterior-only (68.4%), and anterior-posterior/posterior-anterior- posterior (79.3%) (P = .007).

CONCLUSION: This report provides benchmark rates for overall and specific ACD surgery complications. Although the surgical approach(es) used were likely driven by the type and complexity of deformity, there were significantly higher complication rates associated with combined and posterior-only approaches compared with anterior-only approaches. These findings may prove useful in treatment planning, patient counseling, and ongoing efforts to improve safety of care.

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Reliability assessment of a novel cervical spine deformity classification system

Cervical spine deformity classification

J Neurosurg Spine 23:673–683, 2015

Despite the complexity of cervical spine deformity (CSD) and its signifi cant 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 coef cients) 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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Outcomes of surgical intervention for cervical spondylotic myelopathy accompanying local kyphosis

cervical kyphosis

Eur Spine J (2014) 23:341–346

The surgical strategy for cervical spondylotic myelopathy (CSM) accompanying local kyphosis is controversial. The purpose of the present study was to compare and evaluate the outcomes of two types of surgery for CSM accompanying local kyphosis: (1) laminoplasty alone (LP) and (2) posterior reconstruction surgery (PR) in which we corrected the local kyphosis using a pedicle screw or lateral mass screw.

Methods Sixty patients who presented with local kyphosis exceeding 5º were enrolled. LP and PR were each performed on a group of 30 of these patients; 30 CSM patients without local kyphosis, who had undergone LP, were used as controls. The follow-up period was 2 years or longer. Preoperative local kyphosis angles in LP and PR were 8.3 ± 4.4 and 8.8 ± 5.7, respectively. Preoperative C2–7 angles in LP, PR and controls were -1.7 ± 9.6, -0.4 ± 7.2 and -12.0 ± 5.6, respectively. The recovery rate of the JOA score, local kyphosis angle and C2–7 angle at post-op and follow-up were compared between the groups.

Results The recovery rate of the JOA score in the LP group (32.6 %) was significantly worse than that in the PR group (44.5 %) and that of controls (53.8 %). Local kyphosis angles in the PR and LP groups at follow-up were 4.0 ± 8.6 and 8.0 ± 6.0, respectively. However, although the C2–7 angle at follow-up was improved to -11.1 ± 12.7 in PR, and maintained at -11.6 ± 6.2 in controls, it deteriorated to 0.5 ± 12.7 in LP.

Conclusions The present study is the first to compare the outcomes between LP alone and PR for CSM accompanying local kyphosis. It revealed that PR resulted in a better clinical outcome than did LP alone. This result may be due to reduction of local kyphosis, stabilization of the unstable segment, and/or the maintenance of C2–7 angle until follow- up in the PR group.

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Degree of kyphosis correction and neurological outcome

Cervical lordosis

J Neurosurg Spine 18:537–544, 2013

Reversal of the normal cervical spine curvature, as seen in cervical kyphosis, can lead to mechanical pain, neurological dysfunction, and functional disabilities. Surgical intervention is warranted in patients with sufficiently symptomatic deformities in an attempt to correct the deformed cervical spine. In theory, improved outcomes should accompany a greater degree of correction toward lordosis, although there are few data available to test this relationship. The purpose of this study is to determine if the degree of deformity correction correlates with improvement in neurological symptoms following surgery for cervical kyphotic deformity.

Methods. A retrospective review of 36 patients with myelopathic symptoms who underwent cervical deformity correction surgery between 2001 and 2009 was performed. Preoperative and postoperative radiographic findings related to the degree of kyphosis were collected and compared with functional outcome measures. The minimum follow-up time was 2 years.

Results. A significant relationship was observed between a greater degree of focal kyphosis correction and improved neurological outcomes according to the modified Japanese Orthopaedic Association (mJOA) score (r = -0.46, p = 0.032). For patients with severe neurological symptoms (mJOA score < 12) a trend toward improved outcomes with greater global kyphosis correction was observed (r = -0.56, p = 0.057). Patients with an mJOA score less than 16 who attained lordosis postoperatively had a significantly greater improvement in total mJOA score than patients who maintained a kyphotic position (achieved lordosis: 2.7 ± 2.0 vs maintained kyphosis: 1.1 ± 2.1, p = 0.044).

Conclusions. The authors’ results suggest that the degree of correction of focal kyphosis deformity correlates with improved neurological outcomes. The authors also saw a positive relationship between attainment of global lordosis and improved mJOA scores. With consideration for the risks involved in correction surgery, this information can be used to help guide surgical strategy decision making.

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Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression

J Neurosurg Spine 11:521–528, 2009. DOI: 10.3171/2009.2.SPINE08385

The effects of sagittal kyphotic deformities or mechanical stress on the development of cervical spondylotic myelopathy, or the reduction and fusion of kyphotic sagittal alignment have not been consistently documented. The aim in this study was to determine the effects of kyphotic sagittal alignment of the cervical spine in terms of neurological morbidity and outcome after 2 types of surgical intervention.

Methods. The authors retrospectively reviewed the records of 476 patients who underwent cervical spine surgeries for spondylotic myelopathy between 1993 and 2006 at their university medical center. Among these were identified 43 patients—30 men and 13 women, with a mean age of 58.8 years—who had cervical kyphosis exceeding 10° on preoperative sagittal lateral radiographs obtained in the neutral position, and their cases were analyzed in this study. Anterior decompression with interbody fusion was conducted in 28 patients, and en bloc open-door C3–7 laminoplasty in 15 patients. Both pre- and postoperative neurological, radiographic, and MR imaging findings were assessed in both surgical groups.

Results. The mean preoperative kyphotic angle in all 43 patients was 15.9 ± 5.9° in the neutral position. Seg- mental instability was noted in 26 patients (61%) and reversed dynamic spinal canal stenosis at the level above the local kyphosis in 22 (51%). Preoperative T2-weighted MR images showed high-intensity signal within the cord at and around the level of maximal compression or segmental instability in 28 patients (65%). The mean kyphotic angle in both the neutral and flexion positions was significantly smaller at 4–6 weeks after surgery in the anterior spondylectomy group than in the laminoplasty group (p < 0.001). Furthermore, the angle in the neutral position was significantly smaller on follow-up in the anterior spondylectomy group than in the laminoplasty group (p = 0.034). The transverse area of the spinal cord was significantly larger in the anterior spondylectomy group than in the lamino- plasty group on follow-up (p = 0.037). Preoperative neurological scores (assessed using the Japanese Orthopaedic Association scale) and improvement on follow-up ≥ 2 years after treatment (average 3.3 years) were not significantly different between the 2 groups; however, there was a significant difference in Japanese Orthopaedic Association score at 4–6 weeks postoperatively (p = 0.047).

Conclusions. Kyphotic deformity and mechanical stress in the cervical spine may play an important role in neurological dysfunction. In a select group of patients with kyphotic deformity ≥ 10°, adequate correction of local sagittal alignment may help to maximize the chance of neurological improvement

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