In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Complications of Poor Cervical Alignment in Patients Undergoing Posterior Cervicothoracic Laminectomy and Fusion

    Final Number:

    Brooke T Kennamer; Marc Arginteanu; Frank M. Moore MD; Kevin C. Yao MD; Alfred A. Steinberger MD; Yakov Gologorsky MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: This study sought to determine if a relationship exists between caudal instrumented level and revision rates, neck disability index scores, and cervical alignment in patients undergoing multilevel posterior cervical fusion.

    Methods: This study examined a dataset of all patients undergoing posterior cervical decompression and fusion at =3 levels, terminating between C4 and T4, between January 2010 and December 2015, with at least 12 months of clinical follow-up. Patients were separated into cohorts based on caudal level of the fusion: C6 (or more cranial), C7, T1, or T2 (or more caudal). Revision rate, neck disability index score, sagittal vertical axis, T1 slope, and cervical lordosis were recorded. Linear regression and multivariate analysis was undertaken to identify independent predictors of patient outcomes and disparities between ending constructs in the cervical and the thoracic spine.

    Results: The overall revision rate was 10.8% (n=24). There was no statistically significant difference in the revision rate identified between fusions terminating at C6 or cranial, C7, T1, or T2 and caudal (p=0.74). Revision correlated strongly with increased sagittal vertical axis (p=0.002) and T1 slope (p=0.04). Increased neck disability index score correlated with revision rate (p=0.01), cervical kyphosis (p<0.001), and increased sagittal vertical axis (p=0.04).

    Conclusions: This study suggests that constructs terminating in the proximal thoracic spine have similar revision rates, postoperative neck disability index scores, and radiographic measurements as those terminating in the cervical spine. Poor cervical alignment, as evidenced by increased sagittal vertical axis, cervical kyphosis and T1 slope, predicts need for revision and of poorer clinical outcomes.

    Patient Care: The challenges of operating at the cervicothoracic junction are widely known yet the selection of the most appropriate caudal level for a multilevel posterior cervical decompression and fusion has yet to be elucidated. This study suggests that the caudal level for posterior cervical decompression and fusion may be less important than sagittal vertical axis alignment and other radiographic parameters in terms of overall patient outcomes.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1.Describe the challenges of operating at the cervicothoracic junction. 2. Understand cervical alignment radiographic data and how to use these measures to guide surgical planning. 3.Identify an effective approach to cervicothoracic operations based on preoperative diagnosis, neck disability index score, and cervical alignment.

    References: 1. Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, et al: Cervical Radiographic Alignment. Spine 38:149 - 60, 2013 2. An HS, Vaccaro A, Cotler JM, Lin S: Spinal Disorders at the Cervicothoracic Junction. Spine 19: 2557–64, 1994 3. An HS, Wise JJ, Xu R: Anatomy of the Cervicothoracic Junction: a Study of Cadaveric Dissection, Cryomicrotomy, and Magnetic Resonance Imaging. J Spinal Disord 12: 519 – 25, 1999 4. (Auerbach J, Cho W, Riew KD: Crossing the Cervicothoracic Junction in Multilevel Posterior Cervical Fusions Reduces the Rate of Symptomatic Adjacent Segment Breakdown. 37th Annual Meeting, poster, Cervical Spine Research Society (CSRS), 2009) 5. Cabraja Mario, Abusshi A, Koeppen D, Kroppenstedt S, Woiciechowsky C: Comparison between Anterior and Posterior Decompression with Instrumentation for Cervical Spondylotic Myelopathy: Sagittal Alignment and Clinical Outcome. Neurosurgical Focus 28: E15, 2010 6. Chapman JR, Anderson PA, Pepin C, Toomey S, Newell DW, Grady MS: Posterior instrumentation of the unstable cervicothoracic spine. Journal of Neurosurgery 84: 552- 58, 1996 7. Cheng I, Sundberg EB, Iezza A, Lindsey DP, Riew KD: Biomechanical determination of distal level for fusions across the cervicothoracic junction. Global Spine Journal 5: 282-6, 2015 8. Coe JD, Arlet V, Donaldson W,  Berven S, Hanson DS, Mudiyam R, et al: Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine 31(3): 345–9, 2006 9. Fehlings Michael, Kopjar Sean, Yoon Branko, Sangwook Arnold, Massicotte Paul et al: Anterior Vs. Posterior Surgical Approaches to Treat Cervical Spondylotic Myelopathy: Outcomes Of The Prospective Multicenter AO Spine North America CSM Study In 278 Patients. Spine 38: 2247- 2252, 2013 10. Gilad R, Gandhi CD, Arginteanu MS, Moore FM, Steinberger A, Camins M: Uncorrected Sagittal Plane Imbalance Predisposes to Symptomatic Instrumentation Failure. Spine J 8: 911– 917, 2008 11. Hann S, Chalouhi N, Madineni R, Vaccaro AR, Albert TJ, Harrop J, et al: An Algorithmic Strategy for Selecting a Surgical Approach in Cervical Deformity Correction. Neurosurg Focus 36: E5, 2014 12. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B: Cobb Method or Harrison Posterior Tangent Method: Which to Choose for Lateral Cervical Radiographic Analysis. Spine 25: 2072–2078, 2000. 13. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlmann HH: Radiculopathy and Myelopathy at Segments Adjacent to the Site of a Previous Anterior Cervical Arthrodesis. J Bone Joint Surg Am 81: 519–28, 1999 14. Hyun SJ, Kim KJ, Jahng TA, Kim HJ: Relationship Between T1 Slope and Cervical Alignment Following Multilevel Posterior Cervical Fusion Surgery: Impact of T1 Slope Minus Cervical Lordosis. Spine 41: E396–E402, 2016 15. Ikenaga M, Shikata J, Tanaka C: Long-Term Results Over 10 Years of Anterior Corpectomy and Fusion for Multilevel Cervical Myelopathy. Spine 31:1568–74, 2006 16. Juul T, Sogaard K, Davis AM, Roos EM: Psychometric Properties of the Neck Outcome Score, Neck Disability Index, and Short Form-36 were evaluated in patients with neck pain. J Clin Epidemiol. 79: 31–40, 2016 17. Kawakami M, Tamaki T, Yoshida M , Hayashi N, Ando M, Yamada H: Axial Symptoms and Cervical Alignments After Cervical Anterior Spinal Fusion for Patients with Cervical Myelopathy: J Spinal Disord 12: 50–6, 1999 18. Kong L, Cao J, Wang L, Shen Y: Prevalence of Adjacent Segment Disease Following Cervical Spine Surgery: A PRISMA-Compliant Systematic Review and Meta-analysis. Medicine 95: e4171, 2016 19. Kretzer RM, Hsu W, Hu N, Umekoji H, Jallo GI, McAfee PC, Tortolani PJ, Cunningham BW: Adjacent-Level Range of Motion and Intradiscal Pressure After Posterior Cervical Decompression and Fixation: an In Vitro Human Cadaveric Model. Spine 37: E778- 85, 2012. 20. Kulkarni AG, Dhruv AN, Bassi AJ: Posterior Cervicothoracic Instrumentation: Testing the Clinical Efficacy of Tapered Rods. J Spinal Disord Tech 28: 382– 8, 2015 21. Lali H.S. Sekhon: Posterior Cervical Decompression and Fusion for Circumferential Spondylotic Cervical Stenosis: Review of 50 consecutive cases. Journal of Clinical Neuroscience 13: 23- 30, 2006 22. Lapsiwala S, Benzel E: Surgical Management of Cervical Myelopathy Dealing with the Cervical–thoracic Junction. The Spine Journal 6: S268-S273, 2006 23. Leven D, Cho S: Pseudarthrosis of the Cervical Spine: Risk Factors, Diagnosis, and Management. Asian Spine J: 10(4): 776-786, 2016 24. Naderi S, Ozgen S, Pamir MN, Ozek MM, Erzen C: Cervical Spondylotic Myelopathy: Surgical Results and Factors Affecting Prognosis. Neurosurgery 43: 43 – 9; discussion 9–50, 1998 25. Ondra SL: Biomechanics of spinal deformity correction. Clin Neurosurg 51: 30–5, 2004 26. Passias PG, Oh C, Jalai CM, Worley N, Lafage R, Scheer JK, et al: Predictive Model for Cervical Alignment and Malalignment Following Surgical Correction of Adult Spinal Deformity. Spine 41: E1096– E1103, 2016 27. Protopsaltis T, Bronsard N, Soroceanu A, Henry JK, Lafage R, Smith J, et al: Cervical Sagittal Deformity Develops After PJK in Adult Thoracolumbar Deformity Correction: Radiographic Analysis Utilizing a Novel Global Sagittal Angular Parameter, the CTPA. Eur Spine J 26: 1111-1120, 2017 28. Riew KD, Raich AL, Dettori JR, Heller JG: Neck Pain Following Cervical Laminoplasty: Does Preservation of the C2 Muscle Attachments and/ or C7 Matter? Evid Based Spine Care J 4: 42– 53, 2013 29. Robinson Y, Robinson AL, Olerud C: Complications and Survival After Long Posterior Instrumentation of Cervical and Cervicothoracic Fractures Related to Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis. Spine 40: E227– 33, 2015 30. Scheer JK, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B, et al: Cervical Spine Alignment, Sagittal Deformity, and Clinical Implications: a Review. J Neurosurg Spine 19: 141– 159, 2013 31. Schroeder GD, Kepler CK, Kurd MF, Mead L, Millhouse PW, Kumar P, Nicholson K, Stawicki C, Helber A, Fasciano D, Patel AA, Woods BI, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Vaccaro AR: Is it Necessary to Extend a Multilevel Posterior Cervical Decompression and Fusion to the Upper Thoracic. Spine 41(23): 1845- 9, 2016 32. Shamji MF, Mohanty C, Massicotte EM, Fehlings MG: 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. World Neurosurg 86:112–119, 2016 33. Steinmetz MP, Miller J, Warbel A, Krishnaney AA, Bingaman W, Benzel E: Regional Instability Following Cervicothoracic Junction Surgery. J Neurosurg Spine 4: 278– 84, 2006 34. Tang JA, Scheer JK, Smith JS, Deviren V, Bess S, Hart RA, et al: The Impact of Standing Regional Cervical Sagittal Alignment on Outcomes in Posterior Cervical Fusion Surgery. Neurosurgery 71: 662– 9; discussion 9, 2012 35. Truumees E, Singh D, Geck M, Stokes J: Should Long Segment Cervical Fusions be Routinely Carried Into the Thoracic Spine? –Multi-Center Analysis. Spine Journal 17: 43- 44, [epub ahead of print Sep 28, 2017. DOI:] 36. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, et al: A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine 30(20): 2325– 33, 2005 37. (Wagner PJ, Adams S, Connolly PJ, et al: The Incidence of Instrumentation Failure and Reoperation after Posterior Cervical Fusion that Terminates Cranial or Caudal to the Cervical-Thoracic Junction. The Cervical Spine Research Society Annual Meeting. 2014) 38. White AA III, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Journal of Electromyography and Kinesiology 13: 371– 379, 2003 39. Yang JS, Buchowski JM, Verma V: Construct Type and Risk Factors for Pseudarthrosis at the Cervicothoracic Junction: Spine 40: E613 – 7, 2015

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy