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Background: The lower instrumented vertebrae (LIVs) in cervical deformity (CD) constructs may have varying effects on patient outcomes that are still poorly understood. Objective: The objective of the study is to compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver (PD). Methods: Patients who met radiographic criteria for CD were included in the study. Patients were stratified by PD of deformity: cervical (C) through AMES classification (TS-CL >20 or cervical sagittal vertical axis >40) and thoracic (T) through hyper/hypokyphosis (TK) from T4-T12 (60 < TK < 40). Patients were further stratified by LIV in relation to curve apex (above/below). Univariate and multivariate analyses identified group differences in postoperative health-related quality-of-life and distal junctional kyphosis (DJK) (>10° LIV and LIV + 2) rate up to 1 year. Results: Sixty-two patients were analyzed. Twenty-one patients had a C-PD and 41 had a T-PD by definition. 100% of C-PDs had LIVs below CL apex, while 9.2% of T-PDs had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. By 1 year, C patients trended lower Neck Disability Index (NDI) (21.9 vs. 29.0, P = 0.245), lower numeric rating scales neck pain (4.2 vs. 5.1, P = 0.358), and significantly higher EuroQol five-dimensional questionnaire Visual Analog Scale (69.2 vs. 52.4, P = 0.040). When T patients with LIVs below TK apex were excluded, remaining T patients with LIV above apex had significantly higher 1-year NDI than C patients (37.5 vs. 21.9, P = .05). T patients also trended higher rates of postoperative DJK than C (19.5% vs. 4.8%, P = 0.119). Conclusions: Stopping before apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of DJK. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to evaluate the association of available cervical alignment components through the Ames cervical deformity (CD) classification parameters with the Patient-Reported Outcomes Measurement Information System (PROMIS) physical health domain metrics. Methods: Surgical CD patients (C2–C7 Cobb >10° or C2–C7 sagittal vertical axis [cSVA] >4 cm or T1 slope minus cervical lordosis (TS-CL) >15°) ≥18 years with available baseline (BL) radiographic and PROMIS were isolated in a single-center spine database. Patients were classified according to the Ames CD modifiers for cSVA and TS-CL (low deformity [Low], moderate deformity [Mod], and severe deformity [Sev]). Descriptives and univariate analyses compared population-weighted PROMIS scores for Pain Intensity (PI), Physical Function (PF), and Pain Interference (Int) across CD modifiers. Conditional tree analysis with logistic regression sampling determined the threshold of PROMIS scores for which the correlation with Ames radiographic cutoffs was most significant. Reported cutoff values for Mod (cSVA: 4–8 cm; TS-CL: 15–20°) and Sev (cSVA: >8 cm; TS-CL: >20°) disabilities were used. Results: Two hundred and eight patients (58.8 years, female: 51%, 29.6 kg/m2, Charlson Comorbidity Index: 1.19). BL cSVA modifier by severity: 83.2% Low, 16.8% Mod. No patients met criteria for severe cSVA. BL TS-CL modifier by severity: 18.8% Low, 22.1% Mod, 59.1% Sev. Mean baseline PROMIS scores were as follows: PI score: 89.6 ± 15.4, PF score: 11.9 ± 13.1, Int score: 56.9 ± 6.8. PI did not differ between cSVA and TS-CL severity. Mod cSVA patients and Mod/Sev TS-CL modifier groups trended toward lower PF scores and higher Int scores. A PI score of >96 (odds ratio [OR]: 0.658 [0.303–1.430]), a PF score of <14 (OR: 1.864 [0.767–4.531]), and an Int score of > 57.4 (OR: 1.878 [0.889–3.967]) were predictors of Mod cSVA. A PI score of >87 (OR: 1.428 [0.767–2.659]), a PF score of <14 (OR: 1.551 [0.851–2.827]), and an Int score of >56.5 (OR: 1.689 [0.967–2.949]) were predictors of Sev TS-CL. Conclusions: PROMIS physical health domains were related to the Ames CD classification. Certain BL PROMIS thresholds can be connected to the severity of CD. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort.Objective: The aim was to describe the two-year outcomes for patients undergoing surgical correction of cervical deformity (CD).Background: Adult CD has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear.Materials and Methods: Operative CD patients >18 years with two-year (2Y) health-related quality of life/radiographic data were included. Improvement in radiographic, neurologic, and health-related quality of life outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on Neck Disability Index (NDI), numeric rating scale (NRS) neck, modified Japanese Orthopaedic Association (mJOA) were compared using multivariable analysis controlling for age, and frailty, and invasiveness.Results: One hundred and fifty-eight patients were included in this study. By 2Y, 96.3% of patients improved in Ames cervical sagittal vertical axis modifier, 34.2% in T1 slope minus cervical lordosis (TS-CL), 42.0% in horizontal gaze modifier, and 40.9% in SVA modifier. In addition, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from baseline to 2Y in NDI, NRS Neck, and mJOA, all P <0.05. 59.3% of patients met minimal clinically important difference for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. Ninety-seven patients presented with at least one neurologic deficit at baseline and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of distal junctional kyphosis (DJK) (∆DJKA>10° between lower instrumented vertebra and lower instrumented vertebra-2), of which 17 were distal junctional failure (distal junctional failure-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the two-year follow-up period.Conclusion: Correction of CD results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including DJK or failure remain prevalent. [ABSTRACT FROM AUTHOR]

Thoracolumbar malalignment is often seen in patients presenting with cervical deformities. For operative cervical deformity (CD) patients, it is unknown when the thoracic spine should be included in the construct. To investigate the CD patients in whom fusion to the thoracic spine was warranted. Retrospective cohort study. A total of 72 CD patients. Radiographic parameters; complications, distal junctional kyphosis [DJK], reoperation; Health-Related Quality-of-Life [HRQLs]: NDI, NRS-neck, mJOA. Included: operative CD patients (C2-C7 lordosis < -15°, TS-CL >35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°) with baseline (BL) and up to 2-year (2Y) data. Patients with UIV at or above C4 and LIV extending beyond C7 into the thoracic spine were isolated (CT fusions). CT fusion patients were further stratified to upper and lower thoracic LIVs: T1-T4 [Short Fusion], beyond T4 [Long Fusion]. CT fusion patients were identified as having an optimal outcome at 2-year postop if they 1) did not have DJF and 2) had Virk et al. good clinical outcome [≥2 of the following: NDI <20 or meeting MCID, mild myelopathy (mJOA ≥14), NRS-Neck ≤5 or improved by ≥2 points from baseline]. Univariate analysis compared patients with long fusion and optimal outcome (L/Success) vs patients with short fusion and treatment failure (S/Fail). Multivariate analysis and ROC curve assessed demographic, surgical, and radiographic predictors of S/ Fail and L/S Success status. Conditional inference tree (CIT) determined cut-off values for the continuous predictors. Seventy-two cervical deformity patients with CT fusion included (60.3±9.0years, 60% F, 29.4±7.6 kg/m2, levels fused: 7.8±3.2). By approach, 61% posterior-only and 39% combined. Fifty-nine patients (82%) had CT fusions with LIV of T4 or above, while 13 patients (18%) had fusions extending below T4. Thirty-two patients (44.4%) met the optimal outcome criteria, with no difference by fusion length (p=0.171). Eight patients qualified as long fusions with treatment success, while 35 patients were classified as short fusions with treatment failure. Regression analysis identified the predictors of treatment success in patients with fusion construct extending beyond T4: baseline sacral slope ≤33.5° (OR: 15.0), not undergoing high grade (PSO or VCR) osteotomy (OR: 15.0) and being Ames descriptor type C (OR: 13.5); all p<0.05). ROC curve accounting for these factors resulted in an AUC of 82.0%. Regression analysis identified predictors of treatment failure in patients with short fusion construct: levels fused >6 (OR: 4.3), Ames descriptor type CT (OR: 11.5), Ames cSVA modifier grade 1 or 2 at BL (OR: 4.56), and Flatneck Lafage morphotype (OR: 4.5); all p<0.05. Multivariate regression and ROC curve accounting for these factors resulted in an AUC of 84.3%. Treatment success in patients with fusion constructs extending into the thoracic spine vs treatment failure in patients with short fusions may be reliably predicted by the location of the deformity apex, measures of surgical invasiveness, and preoperative deformity severity. Specifically, treatment success in longer fusions is related to deformity apex in the cervical spine and having deformity where adequate correction does not necessitate high grade osteotomy. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

With an aging population and increased prevalence of cervical deformity, corrective surgery is increasingly utilized as a treatment option. The goal of this study is to examine whether surgical advancements and expansion of knowledge over the years have improved or changed outcomes and the way we approach cervical deformity surgery. To investigate if outcomes or surgical approach have changed over time. Retrospective cohort study of a prospective adult cervical deformity (ACD) database. This study included 119 ACD patients. Complications after ACD surgery within 2 years, HRQL (NDI, mJOA, EQ5D) ACD patients (≥18 years) with complete baseline and 2-year HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into Group I (2013-2014) and Group II (2015-2017) by DOS. Univariate, and multivariate analysis determined differences in surgical, radiographic, and clinical outcomes between groups. A total of 119 cervical deformity patients met inclusion criteria (61.3years, 67%F, BMI: 29kg/m2, CCI: 0.96±1.3). Radiographically at baseline, patients presented with: PT: 18.8± 11.3; PI: 53.0±11.1; PI-LL: -.45±17.7; SVA:-4.34±66.8, TS-CL: 38.1 ±21.4; cSVA: 45.2±25.6. Surgically, 51.3% had osteotomies, 47.1% had a posterior approach, 34.5% combined approach, 18.5% anterior approach, with 7.6± 3.8 levels fused and EBL of 824 mL. Group I consisted of 72 patients, and Group II consisted of 47. Group II had a higher CCI (1.3 vs.72), more cerebrovascular disease (6% vs 0%, both p<0.05), and no difference in age, frailty, deformity, or cervical rigidity. Group II had a lower surgical invasiveness (9 vs 11, p<0.05), trended towards a lower EBL (677 vs 921, p=.124) and shorter LOS (5.1 vs 7.9, p=.065), with no difference in levels fused, approach, reoperations, DJK development, or HRQLs (p>0.05). Controlling for baseline deformity and age, patients in Group II underwent fewer three-column osteotomies.17[.04-.8], (p<0.05). Patients undergoing three-column osteotomies had a deformity primarily in the CT region (48%), followed by C (23%) and T (19%) with a similar distribution between Groups (p>0.05). Additionally, controlling for levels fused and three-column osteotomies, Group II experienced fewer minor complications.3[.09-.96], (p<0.05). At 2 years, Group II had fewer patients with a moderate/high Ames horizontal modifier (71.7% vs 88.2%), fewer patients who were overcorrected in PT (4.3% vs 18.1%) and fewer patients with a +, or ++ deformity in PT SRS-Schwab (9.1% vs 39.5%). In a site-specific subanalysis, controlling for age, CCI, baseline deformity, and levels fused, Group II experienced fewer adverse events than Group I.138[.027-.713], (p=.018). Despite operating on a higher risk cohort with more comorbidity, outcomes have remained consistent, indicating improvements in care. Surgically, there has been a reduction in the number of three-column osteotomies performed, suboptimal realignments, and fewer complications and adverse events. This suggests a better understanding of minimizing the risk of cervical deformity surgery with fewer invasive techniques. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Cervical deformity (CD) corrective procedures are ever-evolving, along with the field of spine surgery. The goal of this study was to examine whether surgical advancements over the years have improved or changed outcomes, and the overall way in which we approach CD surgery. To investigate if operative approach and outcomes of CD have changed over time in respect to surgical advancements. Retrospective cohort study of a prospective cervical deformity database. A total of 123 CD patients (≥18 years) with complete BL and 2Y HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. Complications, HRQL (NDI, mJOA, EQ5D). CD patients (≥18 years) with complete BL and 2-year HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. There were 123 CD patients that met inclusion criteria (61years, 63%F, 29.0kg/m2, CCI: 1±1.4). Radiographically at baseline, patients presented with: PT: 19.6± 11°; PI: 55±13°; PI-LL:.9±17.4°; SVA:-3±68mm, TS-CL: 39 ±21°; cSVA: 45±26. Surgical details were 7.7± 4 levels fused with a mean EBL of 1031mL. By surgical approach, 46% had a posterior approach, 20% anterior, and 37% combined. Group I had 49 patients, and Group II had 74. Group II had a higher CCI (1.1 vs.8, p=.2) while there were no significant differences in number of levels fused, reoperations, DJK development, or HRQL metrics between groups (p>0.05). Overall, 53% of patients had an osteotomy. Patients in Group II had a lower usage of HGO (9% vs 23%, p<0.05). In patients with significant CD, Group II received less HGO (3% vs 33%, p<0.05). In posterior approaches, controlling for age, BL deformity, and CCI, Group II underwent less HGO.32[.08-1.2] p=.1. Controlling for age, CCI, and BL deformity, Group II had lower usage of HGO in rigid deformity (.197[.04-.97], p<0.05). Overtime, patients undergoing cervical deformity surgery received less high-grade osteotomies, even with high grade deformities. Despite operating on a cohort with a greater degree of comorbidity, there was no deterioration in clinical and radiographic outcomes. These findings reflect a better understanding of surgical management and the utility of invasive osteotomies in adult cervical deformity. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The natural shift from a flexible lordotic to relatively fixed kyphotic spine demands special consideration in cervical deformity (CD) surgery. Rigid instrumentation may alter these dynamics considerably depending on a patient's primary driver of deformity and even apex of curvature. The lower instrumented vertebrae (LIV) in CD constructs may have varying effects on patient outcomes that are still poorly understood. To compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver of deformity. Retrospective review of a multicenter cervical fusion dataset. Sixty-two patients undergoing cervical fusion. Baseline (BL) and postop HRQLs: mJOA, NDI, EQ5D, Numeric Rating Scale for Neck/Back pain, distal junctional kyphosis (DJK) rate and magnitude. CD database inclusion: cervical kyphosis >10°, scoliosis (coronal Cobb>10°), positive cervical sagittal imbalance (cSVA>4 cm or TS-CL>10°), or CBVA>25°. Patients were stratified by primary driver of deformity: cervical (C) via Ames classification (TS-CL>20 or cSVA>40) and thoracic (T) via hyper/hypo-kyphosis (TK) from T4-T12 (6010° LIV and LIV+2) rate up to 1 year. Sixty-two CD patients (54.9 yrs, 62.8% F) were analyzed. Mean parameters at BL: TSCL 28.1, cSVA 26.9, T4-T12 angle 38.1. 21 pts had a C primary driver and 41 had a T primary driver by definition. One hundred percent of C primary drivers had LIVs below CL apex, while 9.2% of T primary drivers had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. No differences in HRQLs were found between C and T groups at BL and 3 mo postop. By 1 yr, C patients trended lower NDI (21.9 vs 29.0, p=0.245), lower NRS Neck pain (4.2 vs 5.1,p=0.358), and significantly higher EQ5D VAS (69.2 vs 52.4,p=0.040). When T pts with LIVs below TK apex were excluded, remaining T pts with LIV above apex had significantly higher 1 yr NDI than C pts (37.5vs21.9,p=.05). T patients also trended higher rates of postop DJK than C (19.5% vs 4.8%, p=0.119). No significant differences in mJOA were found (p>0.05). Stopping prior to apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Those with a primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of post-op DJK. Additionally, T patients with LIVs above TK apex had significantly higher NDI and lower EQ5D VAS scores by 1-year. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]