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Passias PG, Williamson TK, Pierce KE, Schoenfeld AJ, Krol O, Imbo B, Joujon-Roche R, Tretiakov P, Ahmad S, Bennett-Caso C, Mir J, Dave P, McFarland K, Owusu-Sarpong S, Lebovic JA, Janjua MB, de la Garza-Ramos R, Vira S, Diebo B, Koller H, Protopsaltis TS, Lafage R, Lafage V. The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score. Spine (Phila Pa 1976) 2024; 49:116-127. [PMID: 37796161 DOI: 10.1097/brs.0000000000004843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN/SETTING Retrospective single-center study. BACKGROUND The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- New York Spine Institute, New York, NY
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Oscar Krol
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Bailey Imbo
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Salman Ahmad
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Jamshaid Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Kimberly McFarland
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | | | - Jordan A Lebovic
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Rafael de la Garza-Ramos
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Heiko Koller
- International Center for Spinal Disorders and Deformity, Orthopedic Department II, Asklepios Clinics Bad Abbach, Bad Tölz, Germany
| | | | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Lamas V, Chapon R, Prost S, Blondel B, Fuentes S, Sauleau EA, Charles YP. Variation of cervical sagittal alignment parameters according to age and pelvic incidence in degenerative spinal deformity patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3624-3633. [PMID: 37505278 DOI: 10.1007/s00586-023-07861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/05/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION In asymptomatic subjects, variations of cervical sagittal alignment parameters according to age and spinopelvic organization have been reported. A large range of compensation phenomena has been observed in degenerative spinal deformity in order to maintain horizontal gaze, but it remains unclear how age and spinopelvic morphology could additionally influence cervical alignment. The aim of this observational retrospective study was to describe the distribution of cervical sagittal alignment parameters according to age and pelvic incidence in subjects with and without degenerative spinal deformity in order to precisely evaluate cervical compensation phenomena in adult spinal deformity (ASD). MATERIAL AND METHODS Radiographs of 478 subjects (327 females and 151 males) were distributed into 235 asymptomatic and 243 deformed subjects. Occipito-cervical parameters were McGregor-C1, McGregor-C2, C1-C2 and occipito-C2 angles. The cervicothoracic inflection point (CTIP) was determined. Caudal cervical sagittal alignment parameters were: C2-C7 lordosis, C2-apex (superior arch), apex-CTIP (inferior arch), occipito-C3 and occipito-C4 angles, C7-slope and T1-slope. The distribution of parameters was analyzed using a Bayesian inference (significant when Pr > 0.975 or Pr < 0.025). Comparisons between asymptomatic and deformed subjects were done after matching on age (40-60 years; > 60 years) and on PI (< 45°; 45-60°; > 60°). RESULTS Among occipito-cervical parameters, there was no significant change in McGregor-C1 angle. However, McGregor-C2 angle was significantly higher in the ASD group (Pr = 0.0029), with influence of age (Pr = 0.023), but PI influence. C1-C2 lordosis was significantly higher in the ASD group compared to the asymptomatic group (Pr < 0.0007), without influence of age or PI noticed. C2-C7 lordosis was also higher in the ASD group (Pr < 0.025) with a role of age and PI (Pr < 0.025). Cervical lordosis in the superior arch was significantly higher in the ASD group (Pr > 0.999), without influence of age or PI. In the inferior arch, the lordosis angle was not modified according to the group, but there was an influence of age (Pr < 0.0007). C7-slope and T1-slope were higher according the age group (Pr < 0.0012), without influence of the group or PI. CONCLUSION This observational study highlights cervical sagittal alignment adaptations in degenerative spinal deformity, matched on age and pelvic incidence. The inferior cervical spine seemed to be modified with a higher lordosis, increasing with age responding to the age-related thoracic kyphosis increase. In addition to that, the superior cervical spine hyperextends more in adult degenerative deformity to maintain horizontal gaze. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Vincent Lamas
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS), Université de Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France.
| | - Renan Chapon
- Service de Neurochirurgie, Centre Hospitalier Universitaire Dijon-Bourgogne, Dijon, France
| | - Solène Prost
- Unité de Chirurgie Rachidienne, Centre Hospitalier Universitaire de La Timone, Aix-Marseille Université, Marseille, France
| | - Benjamin Blondel
- Unité de Chirurgie Rachidienne, Centre Hospitalier Universitaire de La Timone, Aix-Marseille Université, Marseille, France
| | - Stéphane Fuentes
- Service de Neurochirurgie, Centre Hospitalier Universitaire de La Timone, Aix-Marseille Université, Marseille, France
| | - Erik André Sauleau
- Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS), Université de Strasbourg, Strasbourg, France
| | - Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS), Université de Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France
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Malka M, Sardar ZM, Czerwonka N, Coury JR, Reyes JL, Le Huec JC, Bourret S, Hasegawa K, Wong HK, Liu G, Hey HWD, Riahi H, Kelly M, Lenke LG. The Thoracolumbar Inflection Point in a Population of Asymptomatic Volunteers: A Multi-Ethnic Alignment Normative Study Cohort Study. Global Spine J 2023:21925682231193619. [PMID: 37534454 DOI: 10.1177/21925682231193619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES To show population variance in the Inflection Point (IP) and its role in defining maximum Thoracic Kyphosis (TK) and Lumbar Lordosis (LL). METHODS 468 asymptomatic adult volunteers were included in the Multi-Ethnic Normative Alignment Study (MEANS). To find parameters correlating with IP, the vertebrae and discs were numbered such that C7 was 0, T1 was 1, with T1-T2 disc being 1.5, etc. Statistical analysis was performed by a correlation matrix for IP and the 9 other selected parameters along with linear regressions. RESULTS The overall mean IP was 12.44 approximately corresponding to T12-L1 disc with the median being 12.50, range was T8-L4. The cohort was then stratified by sex and ethnicity, but there was no significant difference in IP between groups. IP in younger subjects was 13 (L1), compared to 12.5 (T12-L1 disc) in older subjects (P < .05). IP was moderately correlated with the TK apex (r = .66). No strong correlation was found between IP and LL magnitude or apex, TK magnitude, sacral slope, or Pelvic Incidence (PI). In terms of other sagittal parameters, PI and LL demonstrated a significant positive correlation. PI and TK did not have a strong association. CONCLUSIONS The mean IP was at the T12-L1 disc, however IP ranged from T8 to L4. Older subjects tended to have a relatively more cephalad IP. No radiographic variable was found to be a strong predictor of the IP. TK apex was found to have a moderate correlation.
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Affiliation(s)
- Matan Malka
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Zeeshan M Sardar
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Natalia Czerwonka
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Josephine R Coury
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Justin L Reyes
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Charles Le Huec
- Department of Orthopaedics and Traumatology at the Bordeaux University Hospital, Bordeaux, France
| | - Stephane Bourret
- Department of Orthopaedics and Traumatology at the Bordeaux University Hospital, Bordeaux, France
| | | | - Hee-Kit Wong
- University Spine Centre, National University of Singapore, Singapore
| | - Gabriel Liu
- University Spine Centre, National University of Singapore, Singapore
| | | | - Hend Riahi
- Department of Radiology, Mohamed Kassab Orthopedic Institute, University of Tunis, La Mannouba, Tunisia
| | - Michael Kelly
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | - Lawrence G Lenke
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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Park MS, Moon SH, Kim YW, Lim JK, Jung JH, Kim TS, Reidler JS, Riew KD. The Effect of Cervical Fusion on Functional Sagittal Spinal Alignment Based on the Inflection Point: Case Series Study. Global Spine J 2023; 13:643-650. [PMID: 33719639 DOI: 10.1177/21925682211001795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
STUDY DESIGN A retrospective radiologic study. OBJECTIVE The inflection point is the disc space between a lordotic and kyphotic segment of spine. To our knowledge, there has been no study evaluating changes in functional sagittal alignment determined by inflection points after cervical fusion surgery. The purpose is to identify changes in functional sagittal alignment after cervical fusion as determined by functional segments between cervicothoracic and thoracolumbar inflection points. METHODS Standing radiographs of the sagittal whole spine were taken in 62 patients who underwent cervical fusion procedures. We identified cervicothoracic and thoracolumbar inflection points in the sagittal plane and measured Cobb angles of resulting "functional" cervical, thoracic, and lumbar segments. We also measured the C2 and T1 sagittal vertical axis (SVA) distance to S1 and the anatomic cervical lordosis, thoracic kyphosis, lumbar lordosis, spinopelvic parameters, and T1 sagittal slope. We compared the pre- and post-op values. RESULTS The functional cervical segment and T1 sagittal slope increased postoperatively. C2 and T1 SVA distance to S1 decreased postoperatively. In patients with a single level fusion or lower instrumented vertebra (LIV) proximal or equal to C6, functional cervical segment, and anatomic cervical lordosis increased postoperatively. In those with multiple level fusion or LIV distal or equal to C7, the C2 SVA distance to S1 decreased postoperatively. CONCLUSIONS After cervical fusion surgery, functional cervical sagittal parameters determined by the inflection point improve without changes in the anatomic sagittal parameters. Postoperative changes in functional sagittal parameters were affected by the number of fused levels and LIV.
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Affiliation(s)
- Moon Soo Park
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Woo Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Jin Kyu Lim
- Department of Orthopaedic Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jong Ho Jung
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Tae Soung Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Jay S Reidler
- Department of Orthopedic Surgery, Columbia University, NewYork-Presbyterian Och Spine Hospital, New York, NY, USA
| | - K Daniel Riew
- Department of Orthopedic Surgery, Columbia University, NewYork-Presbyterian Och Spine Hospital, New York, NY, USA
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Weng CH, Huang YJ, Fu CJ, Yeh YC, Yeh CY, Tsai TT. Automatic recognition of whole-spine sagittal alignment and curvature analysis through a deep learning technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2092-2103. [PMID: 35366104 DOI: 10.1007/s00586-022-07189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE Artificial intelligence based on deep learning (DL) approaches enables the automatic recognition of anatomic landmarks and subsequent estimation of various spinopelvic parameters. The locations of inflection points (IPs) and apices (APs) in whole-spine lateral radiographs could be mathematically determined by a fully automatic spinal sagittal curvature analysis system. METHODS We developed a DL model for automatic spinal curvature analysis of whole-spine lateral plain radiographs by using 1800 annotated images of various spinal disease etiologies. The DL model comprised a landmark localizer to detect 25 vertebral landmarks and a numerical algorithm for the generation of an individualized spinal sagittal curvature. The characteristics of the spinal curvature, including the IPs, APs, and curvature angle, could thus be analyzed using mathematical definitions. The localization error of each landmark was calculated from the predictions of 300 test images to evaluate the performance of the landmark localizer. The interrater reliability among a senior orthopedic surgeon, a radiologist, and the DL model was assessed using the intraclass correlation coefficient (ICC). RESULTS The accuracy of the landmark localizer was within an acceptable range (median error: 1.7-4.1 mm), and the interrater reliabilities between the proposed DL model and each expert were good to excellent (all ICCs > 0.85) for the measurement of spinal curvature characteristics. CONCLUSION The interrater reliability between the proposed DL model and human experts was good to excellent in predicting the locations of IPs, APs, and curvature angles. Future applications should be explored to validate this system and improve its clinical efficiency.
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Affiliation(s)
- Chi-Hung Weng
- aetherAI Co., Ltd., 9 F., No. 3-2, Park St., Nangang Dist., Taipei, 115, Taiwan
| | - Yu-Jui Huang
- Spine Division, Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chen-Ju Fu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Yu-Cheng Yeh
- Spine Division, Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
| | - Chao-Yuan Yeh
- aetherAI Co., Ltd., 9 F., No. 3-2, Park St., Nangang Dist., Taipei, 115, Taiwan
| | - Tsung-Ting Tsai
- Spine Division, Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
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