Correlation between cervical lordosis and cervical disc herniation in young patients with neck pain

Headache Characteristics in Chronic Neck Pain Patients with Loss of Cervical Lordosis: A Cross-Sectional Study Considering Cervicogenic Headache

BACKGROUND Loss of cervical lordosis and cervicogenic headache have similar tissue abnormalities, including weakness and atrophy in the neck muscles. Cervicogenic headache is mainly unilateral and is perceived in the occipito-temporo-frontal regions. However, it is not clear whether loss of cervical lordosis is a sign of headache with cervical origin. Herein, we aimed to assess and compare headache characteristics in patients with and without loss of cervical lordosis. MATERIAL AND METHODS This was a cross-sectional study conducted on chronic neck pain patients with (n=38; F/M: 28/10; mean age 33.34±7.73 yrs; range 18 to 45 yrs) and without loss of cervical lordosis (n=38; F/M: 29/9; mean age 33.13±6.41 years; range 20 to 45 years), between May 2019 and November 2019. The 2 groups were assessed and compared for headache characteristics such as frequency, severity, localization, lateralization, duration, and spread scores. Cervical lordosis was assessed on the lateral cervical radiographs by using posterior tangent technique measuring the C2-C7 total cervical spine angle. RESULTS The 2 groups were similar for individual features, including age, sex, employment status, and duration of neck pain (P>0.05). The duration of headache attack was longer in patients with loss of cervical lordosis (5.72±8.12) than in those with normal cervical lordosis (3.29±3.92) (P=0.009). However, there were no significant differences between the 2 groups for headache characteristics, including frequency, severity, localization, lateralization, and spread scores (P>0.05). CONCLUSIONS Patients with loss of cervical lordosis have longer duration of headache attack than those without. Loss of cervical lordosis may be a specific finding associated with longer cervicogenic headache attacks.

Non-Surgical Management of Upper Cervical Instability via Improved Cervical Lordosis: A Case Series of Adult Patients

Injury to the head and neck resulting from whiplash trauma can result in upper cervical instability (UCIS), in which excessive movement at C1 on C2 is observed radiologically. In some cases of UCIS there is also a loss of normal cervical lordosis. We postulate that improvement or restoration of the normal mid to lower cervical lordosis in patients with UCIS can improve the biomechanical function of the upper cervical spine, and thus potentially improve symptoms and radiographic findings associated with UCIS. Nine patients with both radiographically confirmed UCIS and loss of cervical lordosis underwent a chiropractic treatment regimen directed primarily at the restoration of the normal cervical lordotic curve. In all nine cases, significant improvements in radiographic indicators of both cervical lordosis and UCIS were observed, along with symptomatic and functional improvement. Statistical analysis of the radiographic data revealed a significant correlation (R² = 0.46, p = 0.04) between improved cervical lordosis and reduction in measurable instability, determined by C1 lateral mass overhang on C2 with lateral flexion. These observations suggest that enhancing cervical lordosis can contribute to improvement in signs and symptoms of upper cervical instability secondary to traumatic injury.

Relationship between Intervertebral Disc Compression Force and Sagittal Spinopelvic Lower Limb Alignment in Elderly Women in Standing Position with Patient-Specific Whole Body Musculoskeletal Model

The intervertebral disc loading based on compensated standing posture in patients with adult spinal deformity remains unclear. We analyzed the relationship between sagittal alignment and disc compression force (Fm). In 14 elderly women, the alignment of the sagittal spinopelvic and lower extremities was measured. Fm was calculated using the Anybody Modeling System. Patients were divided into low sagittal vertical axis (SVA) and high SVA groups. Comparisons between the two groups were performed and the relationship between the Fm and each parameter was examined using Spearman's correlation coefficient (r). The mean lumbar Fm in the high SVA group was 67.6%; significantly higher than that in the low SVA group (p = 0.046). There was a negative correlation between cervical Fm with T1 slope (r = -0.589, p = 0.034) and lumbar Fm with lumbar lordosis (r = -0.566, p = 0.035). Lumbar Fm was positively correlated with center of gravity-SVA (r = 0.615, p = 0.029), T1 slope (r = 0.613, p = 0.026), and SVA (r = 0.612, p = 0.020). The results suggested sagittal malalignment increased the load on the thoracolumbar and lower lumbar discs and was associated with cervical disc loading.

The Effect of Subsidence on Segmental and Global Lordosis at Long-term Follow-up After Anterior Cervical Discectomy and Fusion

OBJECTIVE

Subsidence following anterior cervical discectomy and fusion (ACDF) may lead to disruptions of cervical alignment and lordosis. The purpose of this study was to evaluate the effect of subsidence on segmental, regional, and global lordosis.

METHODS

This was a retrospective cohort study performed between 2016-2021 at a single institution. All measurements were performed using lateral cervical radiographs at the immediate postoperative period and at final follow-up greater than 6 months after surgery. Associations between subsidence and segmental lordosis, total fused lordosis, C2-7 lordosis, and cervical sagittal vertical alignment change were determined using Pearson correlation and multivariate logistic regression analyses.

RESULTS

One hundred thirty-one patients and 244 levels were included in the study. There were 41 one-level fusions, 67 two-level fusions, and 23 three-level fusions. The median follow-up time was 366 days (interquartile range, 239-566 days). Segmental subsidence was significantly negatively associated with segmental lordosis change in the Pearson (r = -0.154, p = 0.016) and multivariate analyses (beta = -3.78; 95% confidence interval, -7.15 to -0.42; p = 0.028) but no associations between segmental or total fused subsidence and any other measures of cervical alignment were observed.

CONCLUSION

We found that subsidence is associated with segmental lordosis loss 6 months following ACDF. Surgeons should minimize subsidence to prevent long-term clinical symptoms associated with poor cervical alignment.

Perioperative Chanage in Cervical Lordosis and Health-Related Quality-of-Life Outcomes

BACKGROUND

Surgeons have scrutinized spinal alignment and its impact on improving clinical outcomes following anterior cervical discectomy and fusion (ACDF). The primary analysis of this study examines the relationship between change in perioperative cervical lordosis (CL) and health-related quality-of-life (HRQOL) outcomes after ACDF. Secondary analysis evaluates the effects of fusion construct length on outcomes in patients grouped by preoperative cervical alignment.

METHODS

A retrospective cohort study was performed on an institutional database including patients who underwent 1- to 3-level ACDF. C2-C7 CL was measured preoperatively and at final follow-up. For primary analysis, patients were classified based on their perioperative cervical lordotic correction: (1) kyphotic, (2) maintained, and (3) restored. For secondary analysis, patients were categorized based on their preoperative C2-C7 CL: (1) kyphotic, (2) neutral, and (3) lordotic. Demographics and perioperative change in patient-reported outcome measures were compared between groups.

RESULTS

A total of 308 patients were included. A significant difference was noted among maintained, restored, and kyphotic groups in terms of delta physical compositeshort form-12 score (ΔPCS-12) (9.0 vs 10.3 vs 1.5; P = 0.04) and delta visual analog scale score (ΔVAS) for arm pain (-0.9 vs -3.8 vs -0.6; P = 0.03). Regression analysis revealed significantly greater improvement of PCS-12 (β: 8.6; P = 0.03) and VAS arm (β: -2.0; P = 0.03) scores in restored patients compared with kyphotic patients. The length of fusion construct in patients grouped by preoperative cervical alignment had no significant impact on the clinical outcomes on regression analysis.

CONCLUSIONS

Significantly greater PCS-12 and VAS arm improvement were seen in patients whose cervical sagittal alignment was restored to neutral/lordotic compared with those who remained kyphotic. Multivariate analysis demonstrated no association between construct length and perioperative outcomes.

CLINICAL RELEVANCE

The results of this study highlight the importance of sagittal alignment and restoration of CL after short-segment ACDF. Irrespective of preoperative sagittal alignment, the length of ACDF fusion construct does not have a significant impact on clinical outcomes.

LEVEL OF EVIDENCE: 3

Association between Sagittal Cervical Spinal Alignment and Degenerative Cervical Spondylosis: A Retrospective Study Using a New Scoring System

(1) Background: Prolonged neck flexion is thought to cause harmful loading on the cervical spine. Along with the degenerative process, cervical alignment tends to change toward lordotic curvature. The association between cervical alignment and cervical spondylosis remains unclear. (2) Methods: Three raters retrospectively assessed cervical radiographies of outpatients at a tertiary center in 2019 using degenerative cervical spondylosis score (DCS score; a newly developed scoring system), C2-7 absolute rotational angle (ARA), and C2-7 sagittal vertical axis (SVA). (3) Results: A total of 561 patients were included in the analysis. Multiple regression analysis with adjustments for age and sex revealed that C2-7 ARA, rather than SVA, was a significant parameter for degenerative spondylosis. The interaction between age and C2-7 ARA was significant, indicating that the increase in DCS score with increasing age was more pronounced in patients with kyphotic cervical alignment. The direct effect of age on DCS score was 0.349 (95% CI 0.319 to 0.380, p < 0.001) and the proportion of the mediation effect of C2-7 ARA was −0.125 (p < 0.001). (4) Conclusions: C2-7 ARA was significantly associated with DCS after adjustment for both age and sex. Subjects with more kyphotic cervical alignment showed a greater correlation between increased DCS score and older age.

Diagnostic Accuracy of Magnetic Resonance Imaging for Sagittal Cervical Spine Alignment: A Retrospective Cohort Study

(1) Background: Although radiography performed on the subject in an upright position is considered the standard method for assessing sagittal cervical alignment, it is frequently determined, or reported, based on MRI performed on the subject in a supine position. (2) Methods: Cervical alignment observed in both imaging modalities was assessed using four methods: the C2-7 Cobb angle, the absolute rotation angle (ARA), Borden’s method, and the sagittal vertical axis (SVA). Cervical alignment was determined (lordosis, kyphosis, and straight) based on radiography. Then, the diagnostic cut-off values for the MRI images and their corresponding diagnostic accuracies were assessed. (3) Results: The analysis included 142 outpatients. The determined diagnostic cut-off values for lordosis, using three measurements (Cobb angle, ARA, and Borden’s method), were −8.5°, −12.5°, and 3.5 mm, respectively, and the cut-off values for kyphosis were −4.5°, 0.5°, and −1.5 mm, respectively. The cut-off value for SVA > 40 mm was 19.5 mm. The Cobb angle, ARA, and Borden’s method, on MRI, showed high negative predictive values for determining kyphosis. The SVA on MRI measurements also showed high negative predictive values for determining >40 mm. (4) Conclusions: MRI measurements may be predictive of cervical alignment, especially for the exclusion of kyphosis and SVA > 40 mm. However, caution is needed in the other determinations using MRI, as their accuracies are limited.

Clinical impact and imaging results after a modified procedure of ACDF: a prospective case-controlled study based on ninety cases with two-year follow-up

Study design

This is a prospective case-controlled study.

Background

To analyze the postoperative axial pain and cage subsidence of patients presenting with cervical spondylotic myelopathy (CSM) after a modified procedure of ACDF (mACDF).

Methods

Ninety patients with CSM were prospectively collected from 2014 to 2018. The patients were divided into spread group and non-spread group (48:42 ratio) according to the cage placement with or without releasing the Caspar cervical retractor after decompression. Spread group received conventional ACDF and non-spread group received mACDF. Patients were followed-up for at least 24 months after surgery. Radiologic data, including height of intervertebral space and Cobb Angle, were collected. Nervous system function was obtained using JOA scores, and level of pain was assessed using VAS scores.

Results

A total of 90 patients were enrolled and the patients were divided into spread group (n = 48) and none-spread group(n = 42). Cage subsidence of (spread group vs none-spread group) was (0.82 ± 0.68 vs 0.58 ± 0.81) mm, (0.64 ± 0.77 vs 0.34 ± 0.46) mm, (0.48 ± 0.43 vs 0.25 ± 0.28) mm, and (0.45 ± 0.47 vs 0.17 ± 0.32) mm at 3 months, 6 months, 12 months and 24 months, respectively. The period exhibiting the most decrease of the height of intervertebral space was 3 months postoperatively. However, there was no statistical difference in the height of intervertebral space, JOA or VAS scores at the final follow-up between the two groups.

Conclusions

The mACDF can avoid excessive distraction by releasing the Caspar Cervical retractor, restore the “natural height” of cervical vertebra, relieve immediate pain after surgery, and prevent rapid Cage subsidence and the loss of cervical curvature.

Upright Magnetic Resonance Imaging Study of Cervical Flexor/Extensor Musculature and Cervical Lordosis in Females After Helmet Wear

INTRODUCTION

Addition of head-supported mass imparts greater demand on the human neck to maintain functionality. The same head-supported mass induces greater demand on the female spine than the male spine because female necks are comparatively slender. Prevalence of neck pain is greater in military than civilian population because of the head-borne mass (among other factors). The goal of this study is to determine quantifiable parameters related to muscle geometry using female human volunteers and upright magnetic resonance imaging.

MATERIALS AND METHODS

Young healthy subjects were consented. Demographics and head-neck anthropometry were recorded. For all the 7 subjects, the T1- and T2-weighted magnetic resonance imaging in the neutral sitting position was obtained immediately following donning and after 4 hours of continuous wear of standard issued military helmet, while seated in the same posture for 4 hours. Cross-sectional areas of sternocleidomastoid and multifidus muscles from C2-C7, overall and segmental Cobb angles (C2-T1), and centroid and radius of each muscle were calculated. Data were compared with determine differences with the continuous helmet wear.

RESULTS

There were level specific changes in morphological parameters for each of the muscles. Significant difference (P < 0.05) in cross-sectional areas was noted at C2-3 level for sternocleidomastoid and at C3-4 and C5-6 levels for multifidus. For centroid angles, significant difference (P < 0.05) was observed at C2-3 and C5-6 levels for sternocleidomastoid and at C3-4 level for multifidus. There was no significant difference (P > 0.05) in muscle centroid radii between the pre- and posttest conditions.

CONCLUSIONS

Alterations in muscle geometries were muscle specific and level specific: sternocleidomastoid was significant at the upper level, whereas multifidus was significant at the mid-lower cervical spine segments. The insignificant difference in the Cobb angles was attributed to length of time of continuous helmet wear attributed and sample size. Helmet wear can lead to morphometric alterations in cervical flexor/extensor musculature in females.

Clinical and radiological outcomes of kinesiotaping in patients with chronic neck pain: A double-blinded, randomized, placebo-controlled study

Objectives

In this study, we aimed to evaluate the efficacy of kinesiotaping (KT) in patients with chronic non-specific neck pain (NSNP) in terms of pain, disability, cervical range of motion (ROM), and cervical lordosis.

Patients and methods

Between October 2013 and March 2014, a total of 50 patients (10 males, 40 females; mean age 35.1±9.9 years; range, 17 to 62 years) with chronic NSNP were randomized into the KT (n=25) or the sham KT intervention (n=25) groups. Both groups were additionally given a therapeutic exercise (TE) program. The Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores and ROM measurements were recorded at baseline, at the end of treatment, and at one month. Lateral cervical digital radiographs were analyzed by the Cobb, posterior tangent and effective lordosis methods at baseline and at one month after the treatment.

Results

There was a statistically significant decrease in the VAS scores compared to baseline in the KT group. The NDI scores significantly decreased in both groups. The patients in the KT group experienced a significant increase in all planes of cervical ROM after the treatment. Cervical radiographs revealed a significant increase in the Cobb and posterior tangent angles only in the KT group.

Conclusion

Our study results suggest that KT significantly improves VAS, NDI scores, ROM and cervical lordosis angles. The combination of TE and KT is useful in reducing pain and disability and improving ROM and cervical lordosis loss in patients with chronic NSNP.

Temporal Trends in Cervical Spine Curvature of South Korean Adults Assessed by Deep Learning System Segmentation, 2006-2018

IMPORTANCE

The loss of the physiologic cervical lordotic curve is a common degenerative disorder known to be associated with abnormal spinal alignment. However, the changing trends among sex and age groups has not yet been well established.

OBJECTIVE

To analyze the temporal trends in cervical curvature across sex and age groups using an automated deep learning system (DLS).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted using lateral cervical radiographs of 13 691 individuals from January 1, 2006, to December 31, 2018. The degree of anterior vertical curvature was approximated by a DLS approach and convexity measurement method. This population-based study used the Yonsei University College of Medicine Severance Hospital, Seoul, South Korea, cohort database to identify 13 691 consecutive adults (≥18 years of age) who underwent standing lateral radiography in inpatient and outpatient settings.

MAIN OUTCOMES AND MEASURES

The prevalence of kyphotic and straight cervical curve as well as the trends of degree of cervical curvature in 2006 to 2018 among sex and age groups were determined. The DLS performance was validated with quantitative metrics and compared with interobserver and intraobserver variations.

RESULTS

Automatic cervical spine segmentation was identified from lateral radiographs of 13 691 individuals (mean [SD] age, 49.9 [15.3] years; 8051 women [58.8%]). From 2006 to 2018, the decrease in the lordotic curve was significant across both sexes and age groups younger than 70 years, with the decrease more pronounced in women and successively younger generations (female, -0.05; 95% CI, -0.06 to -0.04; 18-29 years of age, -0.06; 95% CI, -0.08 to -0.04; 30-39 years of age, -0.06; 95% CI, -0.08 to -0.04; and 40-49 years of age, -0.05; 95% CI, -0.06 to -0.03; all P < .001). The prevalence of straight and kyphotic curvature had a significant increasing trend for both sexes and young generations, in which individuals 18 to 29 years of age generally had the highest prevalence rates during the study cycle (in 2018, kyphosis, 16.7%; 95% CI, 10.8%-22.5%; straight, 45.5%; 95% CI, 37.7%-53.3%). Similar trends were observed with longitudinal analysis of repeated measures of individuals, with more pronounced decreases in lordotic curvature observed among women and young adults.

CONCLUSIONS AND RELEVANCE

This study suggests a significant, increasing loss of normal cervical lordotic curvature for both sexes and young adults that is greater in progressively younger cohorts and women. Further research is necessary to evaluate associations between neck pain and loss of cervical curvature and address the need for active promotion and practical interventions aimed at neck posture correction.

Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion

Introduction

Cervical kyphotic deformity can be quite debilitating. Most patients present with neck pain, but they can also present with radiculopathy, myelopathy, altered vertical gaze, swallowing problems, and even cosmetic issues from the severe kyphotic deformity. After failing conservative management, surgery remains the only option for halting symptom progression. Surgical options for cervical kyphosis have included anterior-only approaches, posterior-only approaches, or 360- and 540-degree reconstructions. This paper addresses the correction of cervical kyphotic deformity via an anterior-only approach consisting of a four-level anterior cervical discectomy and fusion (ACDF).

Methods

We interrogated our procedure log system and the keyword “anterior cervical discectomy and fusion (ACDF)” was typed into the search bar. All patients with an ACDF for the past five years were reviewed and patients with a four-level ACDF were selected. Chart review was performed and patients presenting with multi-level cervical stenosis with kyphosis were included in the study. Pre- and post-surgery images were reviewed, and the degrees of pre-operative kyphosis and post-operative lordosis were measured.

Results 

Our search produced 20 patients. All the patients had a diagnosis of multi-level cervical stenosis with or without myelopathy and were all symptomatic. Pre-operative kyphosis ranged from 2.3 to 35 (mean 11.5) degrees, and post-operative lordosis ranged from 2 to 38 (mean 16) degrees. All the patients had varying degrees of kyphosis correction post-surgery which ranged from 6 to 44 (mean 27) degrees. Significant improvement or complete resolution of symptoms post-operatively occurred in all patients.

Conclusion 

Four-level ACDF in carefully selected patients can be used to correct cervical alignment in patients presenting with symptomatic multi-level cervical stenosis with kyphosis.