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  • Assessment of Impact of Long-Cassette Standing X-Rays on Surgical Planning for Cervical Pathology: An International Survey of Spine Surgeons

    Final Number:

    Justin S. Smith MD, PhD; Eric Klineberg MD; Christopher I. Shaffrey MD, FACS; Tamir T. Ailon MD, MPH; Virginie Lafage PhD; Frank Schwab MD, PhD; Shay Bess MD; Alan H Daniels MD; Malla Keefe; Justin K Scheer BS; Themistocles Protopsaltis MD; Jens Chapman MD; Michael G. Fehlings MD, PhD, FRCS(C), FACS; Christopher P. Ames MD; International Spine Study Group

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: A recent study demonstrated that long-cassette x-rays can have significant impact on surgical planning for lumbar pathology. It remains unclear whether long-cassette x-rays may be similarly impactful for cervical pathology, especially since some cervical pathologies may be directly related to the TL spine.

    Methods: 15 cases of cervical pathology were presented with a brief vignette and cervical imaging (x-rays and MRI/CT). Surgeons were asked to select a surgical plan, with 6 choices, ranging from least aggressive (cervical anterior- only with discectomy/corpectomy at one or more levels and fusion; 1 point) to the most aggressive (posterior 3- column osteotomy at or below mid-thoracic region with T/L fusion; 6 points). Cases were then reordered and presented with long-cassette standing x-rays and the same question. Results were compared based on cervical imaging only vs addition of long-cassette x-rays. 5 cases (controls) had normal global alignment and 10 cases (study group) had global malalignment.

    Results: 157 surgeons completed the survey, predominantly from North (28%) or South (36%) America and Asia (15.6%). Specialties included orthopedic surgery (62%) and neurosurgery (38%), 79% completed spine fellowship, and responders had a mean 14 yrs in practice that was a mean of 78% spine (32% cervical) and 21% deformity. For study cases, extent of recommended surgery increased significantly with addition of long-cassette x-rays vs cervical imaging only (p=0.003). For control cases, no significant changes in surgery plans were identified with addition of long-cassette x-rays (p=0.106).

    Conclusions: Long-cassette x-rays can have significant impact on surgical planning for cervical pathology. Surgeons should maintain a relatively low threshold for obtaining long-cassette standing x-rays when planning surgical treatment for significant cervical spine pathology.

    Patient Care: This research will improve patient care by providing evidence for the benefits of the practice of maintaining a low threshold for obtaining long-cassette standing x-rays. This change of practice will ensure that global alignment is considered in the treatment of cervical pathologies.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) recognize the importance of global alignment when examining cervical pathologies, and 2) understand the role of long-cassette standing x-rays in planning for surgical treatment of cervical deformity.


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