Introduction: Although previous reports suggest that surgery can improve the pain and functional impact of ACD, approaches and techniques for a given deformity are not standardized.
Methods: 18 ACD cases ranging from moderate to severe deformity were assembled, including a clinical vignette, cervical imaging (x-rays, CT/MRI), and full-length standing x-rays. Cases were reviewed by a panel of deformity surgeons who were queried regarding recommended surgical plan. Plans were compared across surgeons and by deformity type.
Results: The panel included 14 surgeons (10 orthopedic, 4 neurosurgery) that had a mean of 11 yrs in practice, performed an average of 80 instrumented cervical cases/yr, including a mean of 20 ACD cases/yr. There was marked variation in treatment plans across all deformity types (Table). Even for the least complex deformities (moderate mid-cervical apex kyphosis), there was lack of agreement on approach (50% combined A-P, 25%, ant-only, 25% post-only), number of fusion levels: anterior (range: 2-6) and posterior (range: 4-16), and types of osteotomies. As the kyphosis apex moved caudally (CT junction/upper T-spine) and cases with chin-on-chest kyphosis, >80% of surgeons agreed on a post-only approach and >70% recommended a PSO or VCR, but the range in number of anterior (4-8) and posterior (4-27) fusion levels was exceptionally broad. Cases of cervical/CT scoliosis had the least agreement in approach (48% post-only, 33% combined A-P, 17% 540°, 2% ant-only) and had broad variation in number of anterior (2-5) and posterior (6-19) fusion levels, and recommended osteotomies (41% PSO/VCR).
Conclusions: Among a panel of experienced deformity surgeons, there is marked lack of consensus on recommended surgical approach, osteotomies and fusion levels for moderate to severe ACD. Further study is warranted to assess whether specific surgical treatment approaches may be associated with better outcomes.
Patient Care: This research will improve patient care by demonstrating the variability in surgical treatment recommendations between various surgeons, and that patients will likely receive different treatment from different surgeons. This study suggests that further research could help identify which treatment options lead to better outcomes.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) understand the wide variability of treatment recommendations for ACD among experienced spine surgeons, and 2) recognize the importance of determining which surgical treatment approaches may be associated with better outcomes.