Radiographic benefit of incorporating the inflection between the cervical and thoracic curves in fusion constructs for surgical cervical deformity patients

The Variability of the Cervicothoracic Inflection Point: A Cohort Analysis of the Multi-Ethnic Asymptomatic Normative Study (MEANS)

Study DesignCross-sectional Cohort Study.ObjectiveTo determine the cervicothoracic inflection point in an asymptomatic, adult population.IntroductionThe cervicothoracic inflection point (CTIP) is an important sagittal marker to understand for patients with cervical deformities. We aimed to identify the CTIP and understand the relationship to other sagittal alignment markers.Methods468 adult asymptomatic volunteers (18-80 years) from 5 countries (United States, France, Japan, Singapore, Tunisia). All volunteers underwent standing full body, low dose stereo radiographs. The CTIP was identified by measuring the cervical sagittal angle (CSA) and thoracic kyphosis maximum angle (TKMax), using the end vertebra concept. The CTIP was defined as the vertebra or disc between the lower end vertebra of the CSA and upper end vertebra of TKMax. A correlation matrix was utilized to identify the relationship between the CTIP and spinopelvic sagittal parameters of interest.ResultsThe most common CTIP value was the T1 vertebra. CTIPs ranged from C5 to T4, respectively. CTIP showed a weak positive correlation to age (r = 0.10, P = 0.03) and negative correlation to BMI (r = -0.11, P = 0.04). Additionally, CTIP had a minor positive correlation with OC2-CL, C7 slope, T1 slope, T1PA, T1-T12 TK, and T4-T12 TK, all statistically significant. Linear regression demonstrated increased cervical lordosis and increased TK was associated with more caudal CTIP segments.ConclusionCTIP segments ranged from C5 to T4, with the most common segment being T1. Understanding the relationship of the CTIP to other sagittal variables is critical to patients with CD.

Anterior To Psoas lumbar and lumbosacral combined with posterior reconstruction in Adult Spinal Deformity: A bicentric European study

Introduction

Lateral lumbar fusion via the trans-psoas approach is popular in adult deformity reconstruction. To overcome its limitations (neurological damage to the plexus and lack of applicability to the lumbosacral junction), a modified anterior-to-psoas (ATP) approach has been described and used.

Research question

To investigate the results of ATP lumbar and lumbosacral fusion, in a cohort of adult patients treated with combined anteroposterior approaches for adult spinal deformity (ASD).

Materials and methods

ASD patients surgically treated at two tertiary spinal centres were followed up. Forty patients were treated with combined ATP and posterior surgery: 11 with open lumbar lateral interbody-fusions (lumbotomy LLIF) and 29 with lesser invasive oblique lateral interbody-fusions (OLIF). Preoperative demographics, aetiology, clinical characteristics, and spinopelvic parameters were comparable between the two cohorts.

Results

At a minimum 2-year follow-up, both cohorts showed significant improvements in patient reported outcome measures (PROMs), i.e. Visual Analogue Scale and Core Outcome Measures Index, as well as radiological parameters, with no significant differences based on the type of surgical approach. No significant differences were found in major (P ​= ​0.457) and minor (P ​= ​0.071) complications between the two cohorts.

Discusson and conclusion

Anterolateral lumbar interbody fusions, whether performed via a direct or oblique approach, proved to be safe and effective adjuvants to posterior surgery in patients with ASD. No significant complication differences were noted between techniques. In addition, the anterior-to-psoas approaches limited the risks of post-operative pseudoarthrosis by providing solid anterior support to lumbar and lumbosacral segments, demonstrating a positive impact on PROMS.

To cross or not to cross the cervicothoracic junction in multilevel posterior cervical fusion: a systematic review and meta-analysis

BACKGROUND

Inclusion of the cervicothoracic junction (CTJ) during decision-making regarding the surgical level of multilevel posterior cervical fusion (PCF) surgery remains the subject of debate, largely due to a lack of studies on the topic. Thus, we considered that meta-analysis based on recent high-quality clinical studies might enable better-informed decision-making regarding the selection of the distal level of multilevel PCF, particularly concerning the advisability of crossing the CTJ.

PURPOSE

To compare the outcomes of patients who underwent multilevel PCF with or without crossing the CTJ (the thoracic and cervical groups, respectively) by the distal construct.

STUDY DESIGN

A systematic review and meta-analysis.

METHODS

We searched the Cochrane, Embase, and Medline databases for articles that compared the intra- and post-operative outcomes of patients who underwent multilevel PCF surgery with or without extension of surgery to include the CTJ, using January 7, 2021, as the publication cutoff date. Group differences in primary and secondary outcome measures were analyzed for significance (p<.05). All reported means were pooled.

RESULTS

A total of 1,904 publications were assessed, and eight studies met the study criteria. The cervical group had a significantly greater fusion rate than the thoracic group (p=.03), but higher adjacent segment disease (ASD) and reoperation rates (ASD: OR=3.15, p=.007; reoperation: OR=1.93, p=.008). As regards surgical outcomes, mean blood loss was less and operation time was shorter in the cervical group (p=.008 and .009, respectively). However, mean hospital stays were not significantly different (p=.12), and neither were the rates of complications, such as metal failure and hematoma.

CONCLUSIONS

In the current study, fusion rate, blood loss, and operation time were better in the cervical group than in the thoracic group, but ASD incidence and ASD-related complication rates at the CTJ were greater in the cervical group. For patients with higher risk factors for adjacent-segment degeneration, crossing the CTJ may be warranted.