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Study Design Retrospective Cohort Study Objectives Mid-term Anterior Vertebral Body Tethering (AVBT) results demonstrate an acceptable degree of clinical success, yet the revision rate remains notably higher than fusion. Fulcrum-bending radiographs have previously been shown to more reliably predict radiological outcomes in Adolescent Idiopathic Scoliosis (AIS) as compared to supine-lateral bending radiographs. This study aims to discern how Fulcrum Flexibility Rate (FFR) correlates with Correction Rate (CR) and establish whether this can reliably predict residual deformity following AVBT surgery. Methods A review of 38 consecutive AIS patients undergoing thoracic AVBT between 2015 – 2020 was performed. Preoperative (standing and fulcrum-bending) and postoperative (first-erect) radiographs were evaluated for curve magnitude using the Cobb-method. The FFR, CR and Fulcrum Bending Correction Index (FBCI) were calculated. Patients were also percentile-ranked according to their FFR and dichotomized into flexible and rigid cohorts for comparison. Student t-test, Pearson correlation and linear stepwise regression was applied. Results: AVBT resulted in a significant improvement in the major Cobb angle (Preoperative: 50.9±7.5° vs Postoperative: 19.9±9.4°; P < .0001) with a mean FBCI of 98.0%. Bivariate correlation revealed a moderate relationship between fulcrum-bending and first-erect Cobb angle (r = .5306, P = .0006). Linear regression demonstrated a predictive relationship between fulcrum-bending and first-erect Cobb using the equation ‘Postoperative Cobb = 7.5 + .65(Fulcrum-bending Cobb).’ Conclusion: This is the first study to demonstrate the ability of fulcrum-bending radiographs to predict early radiographic outcomes following AVBT, ‘timepoint-zero’ for the growth modulation process.

Background Patellofemoral arthroplasty (PFA) is an emerging treatment for patients with isolated patellofemoral compartment osteoarthritis. The medial parapatellar approach is the standard arthrotomy but has been shown in total knee arthroplasty to damage the patellar blood supply and increase postoperative patellar instability. The lateral parapatellar approach is an alternative that may reduce the risk of these outcomes. The purpose of this study is to compare the radiographic measures of patellar tracking and patient-reported outcomes of the medial and lateral parapatellar approaches in PFA. Methods Between 2012 and 2019, a retrospective review was performed of 136 knees undergoing PFA at a single institution. Patients were separated by preoperative congruence angle and then surgical approach into 3 cohorts. Preoperative and postoperative patellar tilt and congruence angle were measured. Preoperative and minimum 6-month postoperative patient-reported outcomes scores were collected. Results There were no significant differences in the mean postoperative congruence angle and postoperative patient-reported outcomes among the 3 cohorts. Mean postoperative patellar tilt was normalized only in the abnormal congruence angle/lateral approach group to 2.80° (standard error, 1.85). Conclusion Congruence angle was improved regardless of surgical approach. Patellar tilt was normalized only for the lateral approach in patients with abnormal preoperative congruence angle. There were no significant differences in preoperative and postoperative scores between groups except for preoperative 12-item Short Form Mental Health Survey scores. This study supports that the lateral approach offers improved postoperative patellar tilt compared to a medial approach for PFA while achieving similar patient-reported outcomes.

Study Design: This was a single-center retrospective review. Objectives: To explore how age and gender affect PROMIS scores compared with traditional health-related quality of life (HRQL) in spine patients. Methods: Patients presenting with a primary complaint of back pain (BP) or neck pain (NP) were included. Legacy HRQLs were Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS). PROMIS Physical Function (PF), Pain Intensity (Int), and Pain Interference (Inf) were also administered to patients in a clinical setting. Patients were grouped by chief complaint, age (18-44, 45-64, 65+ years) and gender. Two parallel analyses were conducted to identify the effects of age and gender on patient-reported outcomes. Age groups were compared after propensity-score matching by VAS-pain and gender. Separately, genders were compared after propensity-score matching by age and VAS-pain. Results: A total of 484 BP and 128 NP patients were matched into gender cohorts (n = 201 in each BP group, 46 in each NP group). Among BP patients, female patients demonstrated worse disability by ODI (44.15 vs 38.45, P = .005); PROMIS-PF did not differ by gender. Among NP patients, neither legacy HRQLs nor PROMIS differed by gender when controlling for NP and age. BP and NP patients were matched into age cohorts (n = 135 in each BP group and n = 14 in each BP group). Among BP patients, ANOVA revealed differences between groups when controlling for BP and gender: ODI ( P < .001), PROMIS-PF ( P = .018), PROMIS-Int ( P < .001) PROMIS-Inf ( P < .001). Among NP patients, matched age groups differed significantly in terms of NDI ( P = .032) and PROMIS-PF ( P = .022) but not PROMIS-Int or PROMIS-Inf. Conclusions: Age and gender confound traditional HRQLs as well as PROMIS domains. However, PROMIS offers age and gender-specific scores, which traditional HRQLs lack.

BACKGROUND Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P

Retrospective cohort study.The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS.Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings.Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications.Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure.Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively.This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

Retrospective review from a single institution.To evaluate intraoperative T1-pelvic angle (TPA), T4PA, and T9PA as predictors of postoperative global alignment after adult spinal deformity (ASD) surgery.Malalignment following adult spinal surgery is associated with disability and correlates with health-related quality of life. Preoperative planning and intraoperative verification are crucial for optimal postoperative outcomes. Currently, only pelvic incidence minus lumbar lordosis (PI-LL) mismatch has been used to assess intraoperative correction.Patients undergoing ≥4-level spinal fusion with full-length pre-, intra-, and first postoperative calibrated radiographs were included from a single institution. Alignment measurements were obtained for sagittal vertical axis (SVA), PI-LL, TPA, T4PA, and T9PA. The whole cohort was divided into upper thoracic (UT: UIVT7) and lower thoracic fusions (LT: UIVT7). Change was assessed between phases, and a subanalysis was included for UT and LT groups to compare alignment changes for differing extent of proximal fusion in the sagittal plane.Eighty patients (mean 63.4 years, 70% female, mean levels fused 11.9) underwent significant ASD correction (ΔPI-LL = 22.1°; ΔTPA = 13.8°). For all, intraoperative TPA, T4PA, and T9PA correlated with postoperative SVA (range, r = 0.41-0.59), whereas intraoperative PI-LL correlated less (r = 0.38). For UT (n = 49), all spinopelvic angles and LL were similar intraoperative to postoperatively (p.09). For LT (n = 31), intraoperative and postoperative T9PA and LL were similar (p.10) but TPA and T4PA differed (p.02). For UT, all intraoperative and postoperative spinopelvic angles strongly correlated (r = 0.8-0.9). For LT, intraoperative to postoperative T9PA strongly correlated (r = 0.83) and TPA, T4PA, and LL correlated moderately (r = 0.65-0.70). LT trended toward more reciprocal kyphosis postoperatively (8.1° vs. 2.6°; p = .059).Intraoperative measurements of TPA, T4PA, and T9PA correlated better with postoperative global alignment than PI-LL, demonstrating their utility in confirming alignment goals. When comparing intraoperative to postoperative films, only T9PA was similar in LT whereas all spinopelvic angles were similar in UT. Reciprocal kyphosis in unfused segments of LT fusions may account for difference in TPA and T4PA from intraoperative to postoperative films.Level III.

Background: Patellofemoral Arthroplasty (PFA) has been shown to be successful in restoring knee function and quality of life in patients with the isolated patellofemoral disease. Patient sa...

STUDY DESIGN A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017. OBJECTIVE To validate the association of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain. SUMMARY OF BACKGROUND DATA PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However, literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain. METHODS Inclusion criteria were age >18 years and a primary complaint of neck pain. The NDI; Visual Analog Scale (VAS) back, neck, arm, and leg; and PROMIS physical function, pain intensity, and pain interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain by controlling for neck pain. Bivariate correlations and independent samples t tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS. RESULTS Approximately, 130 patients were included. NDI correlated strongly to PROMIS physical function (r = -0.771, P

Background: Klippel–Feil syndrome (KFS) includes craniocervical anomalies, low posterior hairline, and brevicollis, with limited cervical range of motion; however, there remains no consensus on inheritance pattern. This study defines incidence, characterizes concurrent diagnoses, and examines trends in the presentation and management of KFS. Methods: This was a retrospective review of the Kid's Inpatient Database (KID) for KFSpatients aged 0–20 years from 2003 to 2012. Incidence was established using KID-supplied year and hospital-trend weights. Demographics and secondary diagnoses associated with KFS were evaluated. Comorbidities, anomalies, and procedure type trends from 2003 to 2012 were assessed for likelihood to increase among the years studied using ANOVA tests. Results: Eight hundred and fifty-eight KFS diagnoses (age: 9.49 years; 51.1% females) and 475 patients with congenital fusion (CF) (age: 8.33 years; 50.3% females) were analyzed. We identified an incidence rate of 1/21,587 discharges. Only 6.36% of KFS patients were diagnosed with Sprengel's deformity; 1.44% with congenital fusion. About 19.1% of KFS patients presented with another spinal abnormality and 34.0% presented with another neuromuscular anomaly. About 36.51% of KFS patients were diagnosed with a nonspinal or nonmusculoskeletal anomaly, with the most prevalent anomalies being of cardiac origin (12.95%). About 7.34% of KFS patients underwent anterior fusions, whereas 6.64% of KFS patients underwent posterior fusions. The average number of levels operated on was 4.99 with 8.28% receiving decompressions. Interbody devices were used in 2.45% of cases. The rate of fusions with

BACKGROUND: Adult sagittal spinal deformity (SSD) leads to the recruitment of compensatory mechanisms to maintain standing balance. After regional spinal compensation is exhausted, lower extremity compensation is recruited. Knee flexion, ankle flexion, and sacrofemoral angle increase to drive pelvic shift posterior and increase pelvic tilt. We aim to describe 2 summary angles termed ankle-pelvic angle (APA) and global lower extremity angle (GLA) that incorporate all aspects of lower extremity and pelvic compensation in a comprehensive measurement that can simplify radiographic analysis. METHODS: Full-body sagittal stereotactic radiographs were retrospectively collected and digitally analyzed. Spinal and lower extremity alignment were quantified with existing measures. Two angles—APA and GLA—were drawn as geometrically complementary angles to T1-pelvic angle (TPA) and global sagittal axis (GSA), respectively. Regression analysis was used to represent the predictive relationship between TPA and APA and between GSA and GLA. RESULTS: A total of 518 propensity score-matched patient records were available for analysis. Patients with lower extremity compensation had higher APA (21.83° versus 19.47°, P = .007) and GLA (6.03° versus 1.19°, P < .001) than those without compensation. APA and GLA demonstrated strong correlation with TPA (r = 0.81) and GSA (r = 0.77), respectively. Furthermore, the change between preoperative and postoperative values were strongly correlative between ΔAPA and ΔTPA (r = 0.71) and between ΔGLA and ΔGSA (r = 0.77). APA above 20.6° and GLA above 3.6° were indicative of lower extremity compensation. Patients with increased GLA values had significantly higher Oswestry Disability Index scores (48.67 versus 41.04, P = .005). CONCLUSIONS: TPA and GSA are measures of global spinal alignment and APA and GLA, respectively, and are geometrically complementary angles that vary proportionately to SSD and balance the body. APA and GLA increase in SSD patients with lower extremity compensation and decrease with corrective surgery. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: APA and GLA offer a concise and simple method of communicating pelvic and lower extremity compensation.

Patellofemoral arthroplasty (PFA) has garnered attention in recent years as an effective alternative to total knee arthroplasty for patients with symptomatic, isolated patellofemoral joint arthritis. Obesity has previously been identified as a risk factor for revision surgery, but its effect on patient-reported outcome measures (PROMs) has not been evaluated. A retrospective review of a consecutive series of PFA surgeries was conducted at a single, specialized orthopedics center in a major urban center. Patients were dichotomized by body mass index (BMI) as obese (O, BMI >30) or nonobese (NO, BMI: 18.5–25). Demographic, surgical information, and PROMs were collected and analyzed accordingly. Seventy-six patients (41 nonobese, 35 obese) were identified. Patients who were obese presented with significantly worse preoperative PROMs regarding knee-specific quality of life, physical function, and MH or mental health (knee injury and osteoarthritis outcome score quality of life [KOOS QoL], NO: 26.2, O: 14.7, p = 0.019; KOOS PF, NO: 38.2, O: 50.5, p = 0.002; Veterans Rand-12 mental health [VR-12 MH], NO: 54.2, O: 47.0, p = 0.033). No significant difference was seen in improvement in knee function scores between patients who were obese or nonobese (KOOS QoL, NO: 39.5, O: 40.6, p = 0.898; KOOS PS [physical function], NO: –17.8, O: –17.3, p = 0.945). Additionally, no difference in the rate of PFA revision was observed and there were no postoperative complications reported. Obese patients with isolated PFA can expect the same improvement in function as nonobese patients following patellofemoral joint arthroplasty. This paper underscores the priority of patient selection in PFA and challenges the notion that surgeons should exclude patients from receiving a PFA on the basis of obesity.

Study design A cross-sectional study. Objective The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. Summary of background data Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding postoperative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery. Methods Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and nonfusion cervical spine surgeries. Results Seventy percent of surgeons returned completed surveys (n = 71). About 80.3% were orthopedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15 years in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs. 24.3%, P = 0.013) for multilevel anterior discectomy and fusion (ACDF) and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than nonfusions (57.7% vs. 31.0%, P = 0.001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics postoperatively. Conclusion This survey-based study highlights the lack of consensus regarding patient "fitness to drive" following cervical spine surgery. The importance of establishing evidence-based guidelines is critical, as recommendations for driving in the postoperative period may have significant medical, legal, and financial implications. Level of evidence 5.

Retrospective radiographic review. To understand the effect of variability in sacral endplate selection in transitional lumbosacral vertebrae (TLSV) and its impact on pelvic, regional, and global spinal alignment parameters. TLSV can have the characteristics of both lumbar and sacral vertebrae. Difficulties in identification of the S1 endplate may come from nomenclature, number of lumbar vertebrae, sacra, and morphology and may influence the interpretation and consistency of spinal alignment parameters. Patients with TLSV were identified and radiographic measurements including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), sagittal vertical axis (SVA), T1-pelvic angle (TPA), pelvic incidence-lumbar lordosis (PI-LL) mismatch, thoracic kyphosis (TK), and spinal inclination (T1SPi) were obtained. Radiographic measurements were performed twice with the sacral endplate at the cephalad and caudal options. Paired t tests assessed the difference between different selection groups. Of 1,869 patients, 70 (3.7%) were found to have TLSV on radiographic imaging. Fifty-eight (82.9%) had lumbarized sacral segments whereas 12 (17.1%) had sacralized lumbar segments. T1-SPi (mean: −1.77°) and TK (mean: 34.86°) did not vary from altering sacral endplate selection. Selection of the caudal TLSV as the sacral endplate resulted in an increase in all pelvic parameters (PI: 66.8° vs. 44.3°, PT: 25.1° vs. 12.7°, and SS: 41.6° vs. 31.6°), regional lumbar parameters (LL: −54.1° vs. 44.0°, PI-LL: 12.7° vs. 0.3°), and global parameters (SVA: 46.1 mm vs. 28.3 mm, TPA: 23.3° vs. 10.8°) as compared to selecting the cephalad TLSV. All mean differences between radiographic parameters were found to be statistically significant (p < .001). Variation in sacral endplate selection in TLSV significantly affects spinal alignment parameter measurements. A standardized method for measuring TLSV is needed to reduce measurement error and ultimately allow more accurate understanding of alignment targets in patients with TLSV. Level III.

Sagittal spinal deformity (SSD) patients utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. This study examines the effect of hip osteoarthritis (OA) on compensatory mechanisms in SSD patients.Patients ≥ 18 years with SSD were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Patients were categorized as limited osteoarthritis (LOA: grade 0-2) and severe osteoarthritis (SOA: grade 3-4). Patients were matched for age and T1-pelvic angle (TPA). Spinopelvic [sagittal vertical axis (SVA), T1-pelvic angle, thoracic kyphosis (TK), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), T1-spinopelvic inclination (T1SPi)] and lower extremity parameters [sacrofemoral angle, knee angle, ankle angle, posterior pelvic shift (P. Shift), global sagittal axis (GSA)] were compared between groups using independent sample t test.136 patients (LOA = 68, SOA = 68) were included in the study. SOA had less pelvic tilt (p = 0.011), thoracic kyphosis (p = 0.007), and higher SVA and T1Spi (p 0.001) than LOA. SOA had lower sacrofemoral angle (p 0.001) and ankle angle (p = 0.043), increased P. Shift (p 0.001) and increased GSA (p 0.001) compared to LOA. There were no differences in PI-LL, LL, knee angle, or cervical alignment (p 0.05).Patients with coexisting spinal malalignment and SOA compensate by pelvic shift and thoracic hypokyphosis rather than PT, likely as a result of limited hip extension secondary to SOA. As a result, SOA had worse global sagittal alignment than their LOA counterparts. These slides can be retrieved under Electronic Supplementary Material.

STUDY DESIGN Retrospective analysis. OBJECTIVE Determine whether deformity corrections should vary by pelvic incidence (PI). SUMMARY OF BACKGROUND DATA Alignment targets for deformity correction have been reported for various radiographic parameters. The T1 pelvic-angle (TPA) has gained in applications for adult spinal deformity (ASD) surgical-planning since it directly measures spinal alignment separate from pelvic- and lower-extremity compensation. Recent studies have demonstrated that ASD corrections should be age specific. METHODS A prospective database of consecutive ASD patients was analyzed in conjunction with a normative spine database. Clinical measures of disability included the Oswestry Disability Index (ODI) and Short Form 36 Survey (SF-36) Physical Component Score (PCS). Baseline relationships between TPA, age, PI, and ODI/SF-36 PCS scores were analyzed in the ASD and asymptomatic patients. Linear regression modeling was used to determine alignment targets based on PI and age-specific normative SF-36-PCS values. RESULTS Nine hundred three ASD patients (mean 53.7 yr) and 111 normative subjects (mean 50.7 yr) were included. Patients were subanalyzed by PI: low, medium, high ( 75); and age: elderly (>65 yr, n = 375), middle age (45-65 yr, n = 387), and young (18-45 yr, n = 141). TPA and SRS-Schwab parameters correlated with age and PI in ASD and normative subjects (r = 0.42, P

BACKGROUND: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. METHODS: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index

Background: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. Methods: The Kids9 Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P Results: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P Conclusions: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. Level of Evidence: III Clinical Relevance: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

BACKGROUND CONTEXT Chin-Brow Vertical Angle (CBVA) is not routinely measured on radiographs even though it is a strong assessor of horizontal gaze. STUDY DESIGN Retrospective cohort study of patients with full-body stereoradiographs and a primary cervical diagnosis at the time of presentation. PURPOSE Assess the utility of McGregor's Slope (McGS) and Slope of Line of Sight (SLS) as surrogate markers for the CBVA in cervical spine pathology. METHODS A retrospective review of patients with full-body stereoradiographs was performed. Patients were ≥18 years of age with a primary cervical diagnosis. Analysis of CBVA, McGS, and SLS was conducted as markers of horizontal gaze. Sagittal alignment was characterized by: pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle (TPA), sagittal vertical axis (SVA), T2-T12 thoracic kyphosis, C2-C7 SVA (cSVA), C2-C7 Cervical lordosis, T1-Slope minus Cervical Lordosis (TS-CL), and C2-Slope (C2S). A subgroup analysis was performed in patients with cervical deformity. Independent sample t tests and paired t tests compared radiographic alignment. Pearson correlations characterized linear relationships. Linear regression analysis identified relationships between the parameters. RESULTS In all, 329 patients were identified with primary cervical spine diagnoses. Chin-Brow Vertical Angle was visible in 171 patients (52.0%), McGS in 281 (85.4%), and SLS in 259 (78.7%). Of the 171 patients with visible CBVA, the mean CBVA was 2.30±7.7, mean McGS was 5.02±8.1, and mean SLS was −1.588±2.03. Chin-Brow Vertical Angle strongly correlated with McGS (r=0.83) and SLS (r=0.89) with p CONCLUSIONS This study demonstrates that McGS and SLS serve as strong, positive correlates for CBVA. The reported mean differences between these measurements provide a useful conversion, broadening CBVA's use as a radiographic assessment of horizontal gaze.

With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients.All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed.In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P.05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge,75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P.01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost.Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.

Background: This study aims to describe properties of adult spinal deformity (ASD) revisions relative to primary surgeries and determine clinical variables that can predict revision. ASD is a common pathology that can lead to decreased quality of life, pain, physical limitations, and dissatisfaction with self-image. Durability of interventions for deformity treatment is of paramount concern to surgeons, as revision rates remain high. Methods: Patients undergoing thoracolumbar fusion, five or more levels, for scoliosis (primary diagnosis ICD-9 737.x) were identified on a state-wide database. Primary and revision (returning for re-fusion procedure) surgeries were compared based on demographic, hospital stay, and clinical characteristics. Differences between primary and revision surgeries, and predictors of primary surgeries requiring revision, utilized binary logistic regression controlling for age, comorbidity burden, and levels fused. Results: A total of 1,063 patients (average 7.4 levels fused, mean age: 47.6 years, 69.0% female) undergoing operative treatment for ASD were identified, of which 123 (average 7.1 levels fused, 11.6%, mean age 61.43, 80.5% female) had surgical revision. Primary surgeries were ~0.3 levels longer (P=0.013), used interbody ~11% more frequently (P=0.020), and used BMP ~12% less frequently (P=0.008). Revisions occurred 176.4 days after the primary on average. The most frequent causes of revisions were: 43.09% implant failure, 24.39% acquired kyphosis, and 14.63% enduring scoliosis. After controlling for age, comorbidities, and levels fused older, more comorbid, female, and white-race patients were more likely to be revised. Upon multivariate regression, after controlling for age and levels fused, overall complications remained non-different (OR: 0.8, 95% CI: 0.6–1.2). However, revision remained an independent predictor for infection (OR: 5.5, 95% CI: 2.8–10.5). Conclusions: In a statewide database with individual patient follow up of up to 4 years 10% of ASD patients undergoing scoliosis correction required revision. Revision surgeries had higher infection incidence.

The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD).Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA]5 cm, pelvic incidence minus lumbar lordosis [PI-LL]10°, coronal curvature20° or pelvic tilt20°). Patients were stratified by age (40, 40-65, and ≥65 years) and body mass index (25, 25-30, and30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests.A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P0.05).After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.

OBJECTIVEPreoperative planning of thoracolumbar deformity (TLD) surgery has been shown to improve radiographic and clinical outcomes. One of the confounders in attaining optimal postoperative alignment is the reciprocal hyperkyphosis of unfused thoracic segments. Traditional planning utilizes standing radiographs, but the value of sitting radiographs to predict thoracic flexibility has not been investigated. Authors of the present study propose that alignment changes from a sitting to a standing position will predict changes in unfused thoracic segments after TLD correction.METHODSPatients with degenerative spine pathology underwent preoperative sitting and standing full-spine stereotactic radiography. A subset of TLD patients who had undergone corrections with minimum T10-pelvis fusions was analyzed in terms of pre- to postoperative alignment. Radiographic parameters were analyzed, including the T1 pelvic angle (TPA), T1–L1 pelvic angle (TLPA), lumbar pelvic angle (LPA), pelvic tilt (PT), mismatch between pelvic incidence and lumbar lordosis (PI-LL mismatch), and T2–12 kyphosis (TK). Thoracic compensation was calculated as the expected TK minus actual TK (i.e., [2/3 × PI] − actual TK). Statistical analysis consisted of paired and unpaired t-tests and linear regression analysis.RESULTSThe authors retrospectively identified 137 patients with full-body standing and sitting radiographs. The mean age of the patients was 60.9 years old, 60.0% were female, and the mean BMI was 27.8 kg/m2. The patients demonstrated significantly different radiographic alignments in baseline spinopelvic and global parameters from the preoperative sitting versus the standing positions: LL (−34.20° vs −47.87°, p < 0.001), PT (28.31° vs 17.50°, p < 0.001), TPA (27.85° vs 16.89°, p < 0.001), TLPA (10.63° vs 5.17°, p < 0.001), and LPA (15.86° vs 9.67°, p < 0.001). Twenty patients (65.0% female) with a mean age of 65.3 years and mean BMI of 30.2 kg/m2 had TLD and underwent surgical correction (pre- to postoperative standing change in TPA: 33.90° to 24.50°, p = 0.001). Preoperative sitting radiographs demonstrated significant differences in alignment compared to postoperative standing radiographs: larger TPA (39.10° vs 24.50°, p < 0.001), PT (35.40° vs 28.10°, p < 0.001), LL (−11.20° vs −44.80°, p < 0.001), LPA (22.80° vs 14.20°, p < 0.001), and unfused Cobb (T2 to upper instrumented vertebra [UIV] Cobb angle: 19.95° vs 27.50°, p = 0.039). Also in the TLD group, mean thoracic compensation was 6.75°. In the linear regression analysis, the change from sitting to standing predicted pre- to postoperative changes for TK and the unfused thoracic component of TPA (5° change in preoperative sitting to preoperative standing corresponded to a pre- to postoperative change in standing TK of 6.35° and in standing TPA of 7.23°, R2 = 0.30 and 0.38, respectively).CONCLUSIONSSitting radiographs were useful in demonstrating spine flexibility. Among the TLD surgery group, relaxation of the unfused thoracic spine in the sitting position predicted the postoperative increase in kyphosis of the unfused thoracic segments. Sitting radiographs are a useful tool to anticipate reciprocal changes in thoracic alignment that diminish global corrections.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden.METHODSA retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores.RESULTSA total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = −0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%).CONCLUSIONSPROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

OBJECTIVEVerifying the adequacy of surgical correction of adult spinal sagittal deformity (SSD) leads to improved postoperative alignment and clinical outcomes. Traditionally, surgeons relied on intraoperative measurements of lumbar lordosis (LL) correction. However, T-1 pelvic angle (TPA) and its component angles more reliably predict postoperative alignment. While TPA is readily measured on standing radiographs, intraoperative radiographs offer poor resolution of the bicoxofemoral axis. A method to recreate this radiographic landmark by extrapolating preoperative measurements has been described. The authors aimed to assess the reliability of measurements of global spinal alignment obtained via geometrical reconstitution of the bicoxofemoral axis on prone intraoperative radiographs.METHODSA retrospective review was performed. Twenty sets of preoperative standing full-length and intraoperative prone 36-inch lateral radiographs were analyzed. Pelvic incidence (PI) and sacral to bicoxofemoral axis distance (SBFD) were recorded on preoperative films. A perpendicular line was drawn on the intraoperative radiograph from the midpoint of the sacral endplate. This was used as one limb of the PI, and the second limb was digitally drawn at an angle that reproduced the preoperatively obtained PI, extending for a distance that matched the preoperative SBFD. This final point marked the obscured bicoxofemoral axis. These landmarks were used to measure the L-1, T-9, T-4, and T-1 pelvic angles (LPA, T9PA, T4PA, and TPA, respectively) and LL. Two spine fellows and 2 attending spine surgeons made independent measurements and repeated the process in 1 month. Mixed-model 2-way intraclass correlation coefficient (ICC) and Cronbach’s α values were calculated to assess interobserver, intraobserver, and scale reliability.RESULTSInterobserver reliability was excellent for preoperative PI and intraoperative LPA, T9PA, and T4PA (ICC = 0.88, 0.84, 0.84, and 0.93, respectively), good for intraoperative TPA (ICC = 0.68), and fair for preoperative SBFD (ICC = 0.60) and intraoperative LL (ICC = 0.50). Cronbach’s α was ≥ 0.80 for all measurements. Measuring PI on preoperative standing images had excellent intraobserver reliability for all raters (ICC = 0.89, range 0.80–0.93). All raters but one showed excellent reliability for measuring the SBFD. Reliability for measuring prone LL was good for all raters (ICC = 0.71, range 0.64–0.76). The LPA demonstrated good to excellent reliability for each rater (ICC = 0.76, range 0.65–0.81). The thoracic pelvic angles tended to be more reliable at more distal vertebrae (T9PA ICC = 0.71, range 0.49–0.81; T4PA ICC = 0.62, range 0.43–0.83; TPA ICC = 0.56, range 0.31–0.86).CONCLUSIONSIntraoperative assessment of global spinal alignment with TPA and component angles is more reliable than intraoperative measurements of LL. Reconstruction of preoperatively measured PI and SBFD on intraoperative radiographs effectively overcomes poor visualization of the bicoxofemoral axis. This method is easily adopted and produces accurate and reliable prone intraoperative measures of global spinal alignment.

Surgical treatment for spinal metastasis has benefited from improvements in surgical techniques. However, the trends in treatment and outcomes for spinal metastasis surgery have not been well-established in a pediatric population. Patients20 years old with metastatic spinal tumors undergoing spinal surgery were identified in the KID database. Trends for spinal metastases treatment and patient outcomes were analyzed using weight-adjusted ANOVAs. 333 patients were identified in the KID database. The top five primary diagnoses were metastatic brain/spinal cord tumor (19.8%), metastatic nervous system tumor (15.9%), metastatic bone cancer (13.2%), spinal cord tumor (4.2%), and tumor of ventricles (3.0%). There was an increased incidence of spinal metastasis diagnoses from 2003 to 2012 (88.5-117.9 per 100,000; p 0.001) and an increased trend in the incidence of surgical treatment for spinal metastasis from 2003 to 2012 (p = 0.014). The average age was 10.19 ± 6.33 years old and 38.4% were female. The average length of stay was 17.34 ± 24.36 days. Average CCI increased over time (2003: 7.87 ± 1.40, 2012: 8.44 ± 1.39; p = 0.006). The most common surgeries were excision of spinal cord/meninges lesions (69.1%) and decompression of spinal canal (38.1%). Length of hospital stay and in-hospital mortality did not change over time (17.34-18.04 days, p = 0.337; 1.6%-2.9%, p = 0.801). 10.5% of patients underwent a posterior fusion and 22.2% had at least one complication (nervous system, respiratory, dysphagia, infection). The overall complication rate remained stable over time (23.4%-21.8%, p = 0.952). Surgical treatment for spinal metastasis in the last decade has increased, though the complication rates, in-hospital mortality, and length of stay have remained stable.

Study Design Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012. Objectives The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK). Summary of Background Data SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described. Methods SK patients aged 0–20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance. Results A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6–7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27–16.06 years, p = .905). The surgical rate has not changed over time (72.8%–72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ⩾4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%–84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%–8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ⩾4-level fusions has increased (43.5%–89.6%, p < .001), as well as the use of Smith-Peterson (7.8%–23.6%, p < .001) and three-column osteotomies (0.0%–2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001). Conclusions Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education. Levels of Evidence Level III.

Study DesignRetrospective radiological review.PurposeTo quantify the effect of sitting vs supine lumbar spine magnetic resonance imaging (MRI) and change in anterior displacement of the psoas muscle from L1–L2 to L4–L5 discs.Overview of LiteratureControversy exists in determining patient suitability for lateral lumbar interbody fusion (LLIF) based on psoas morphology. The effect of posture on psoas morphology has not previously been studied; however, lumbar MRI may be performed in sitting or supine positions.MethodsA retrospective review of a single-spine practice over 6 months was performed, identifying patients aged between 18–90 years with degenerative spinal pathologies and lumbar MRIs were evaluated. Previous lumbar fusion, scoliosis, neuromuscular disease, skeletal immaturity, or intrinsic abnormalities of the psoas muscle were excluded. The anteroposterior (AP) dimension of the psoas muscle and intervertebral disc were measured at each intervertebral disc from L1–L2 to L4–L5, and the AP psoas:disc ratio calculated. The morphology was compared between patients undergoing sitting and/or supine MRI.ResultsTwo hundred and nine patients were identified with supine-, and 60 patients with sitting-MRIs, of which 13 patients had undergone both sitting and supine MRIs (BOTH group). A propensity score match (PSM) was performed for patients undergoing either supine or sitting MRI to match for age, BMI, and gender to produce two groups of 43 patients. In the BOTH and PSM group, sitting MRI displayed significantly higher AP psoas:disc ratio compared with supine MRI at all intervertebral levels except L1–L2. The largest difference observed was a mean 32%–37% increase in sitting AP psoas:disc ratio at the L4–L5 disc in sitting compared to supine in the BOTH group (range, 0%–137%).ConclusionsThe psoas muscle and the lumbar plexus become anteriorly displaced in sitting MRIs, with a greater effect noted at caudal intervertebral discs. This may have implications in selecting suitability for LLIF, and intra-operative patient positioning.

Patient satisfaction has emerged as a critical metric in assessing patient-reported outcomes for healthcare services. The importance of accurately measuring satisfaction is evidenced by the implementation of patient-reported satisfaction as a tool for healthcare reimbursement by the Centers for Medicare and Medicaid Services (CMS). The Patient Protection and Affordable Care Act have formalized the grading of healthcare quality using patient-centric outcomes. Additionally, data indicate that patient satisfaction is directly governed by patient expectations and this expectation-actuality relationship may have a profound impact on patient outcomes. Healthcare providers must have an understanding of the parameters used to measure patient satisfaction and of the associated impact that treatment satisfaction has on patient-reported outcome measures (PROMs). The purpose of this manuscript is to provide a brief overview of how patient satisfaction is defined and measured and to evaluate the implications of poor patient satisfaction on patient-reported outcomes and perceived surgical success. Additionally, we explore the clinical utility of measuring satisfaction on an institutional scale.

Retrospective review of a prospectively collected database.To define a simplified singular measure of cervical deformity (CD), C2 slope (C2S), which correlates with postoperative outcomes.Sagittal malalignment of the cervical spine, defined by the cervical sagittal vertical axis (cSVA) has been associated with poor outcomes following surgical correction of the deformity. There has been a proliferation of parameters to describe CD. This added complexity can lead to confusion in classifying, treating, and assessing outcomes of CD surgery.A prospective database of CD patients was analyzed. Inclusion criteria were cervical kyphosis10°, cervical scoliosis10°, cSVA4 cm, or chin-brow vertical angle25°. Patients were categorized into two groups and compared based on whether the apex of the deformity was in the cervical (C) or the cervicothoracic (CT) region. Radiographic parameters were correlated to C2S, T1 slope (T1S) and 1-year health-related quality-of-life outcomes as measured by the EuroQol 5 Dimension questionnaire (EQ5D), modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and the Neck Disability Index (NDI).One hundred four CD patients (C = 74, CT = 30; mean age 61 yr, 56% women, 42% revisions) were included. CT patients had higher baseline cSVA and T1S (P 0.05). C2S correlated with T1 slope minus cervical lordosis (TS-CL) (r = 0.98, P 0.001) and C0-C2 angle, cSVA, CL, T1S (r = 0.37-0.65, P 0.001). Correlation of cSVA with C0-C2 was weaker (r = 0.48, P 0.001). At 1-year postoperatively, higher C2S correlated with worse EQ-5D (r = 0.28, P = 0.02); in CT patients, higher C2S correlated with worse NDI, modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and EQ5D (all r 0.5, P≤0.05). Using linear regression, moderate disability by EQ5D corresponded to C2S of 20°(r = 0.08). For CT patients, C2S = 17° corresponded to moderate disability by NDI (r = 0.4), and C2S = 20° by EQ5D (r = 0.25).C2S correlated with upper-cervical and subaxial alignment. C2S correlated strongly with TS-CL (R = 0.98, P 0.001) because C2S is a mathematical approximation of TS-CL. C2S is a useful marker of CD, linking the occipitocervical and cervico-thoracic spine. C2S defines the presence of a mismatch between cervical lordosis and thoracolumbar alignment. Worse 1-year postoperative C2 slope correlated with worse health outcomes.3.