Ramchandran Subaraman, Protopsaltis Themistocles S, Sciubba Daniel, Scheer Justin K, Jalai Cyrus M, Daniels Alan, Passias Peter G, Lafage Virginie, Kim Han Jo, Mundis Gregory, Klineberg Eric, Hart Robert A, Smith Justin S, Shaffrey Christopher, Ames Christopher P
Department of Orthopedic Surgery, NYU Langone medical Center, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY, USA.
Department of Neurosurgery, Johns Hopkins University Medical Center, Baltimore, MD, USA.
Eur Spine J. 2018 Feb;27(2):416-425. doi: 10.1007/s00586-017-5395-x. Epub 2017 Nov 28.
Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively.
Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2-C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°-10°, CK-high > 10°] and cSVA (cSVA-low 0-4 cm, cSVA-mid 4-6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment.
75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0-C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0-C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0-C2 (39°-35°, p = 0.01) which positively correlated with magnitude of deformity correction.
Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.
胸腰椎畸形中已描述了维持站立位对线的相互机制，但原发性颈椎畸形（CD）患者尚未得到研究。本研究旨在报告CD患者颈椎上、下矢状面的代偿机制，并评估其术后变化。
在一个前瞻性手术CD患者数据库中研究整体脊柱对线情况。纳入标准为以下任何一项：颈椎后凸（CK）>10°、颈椎侧弯>10°、C2-C7矢状垂直轴（cSVA）>4cm或颏眉垂直角（CBVA）>25°。本研究排除了之前在C2至T4节段以外进行过融合手术的患者。根据颈椎后凸严重程度增加[颈椎前凸（CL）：<0°，低CK 0°-10°，高CK>10°]和cSVA（低cSVA 0-4cm，中cSVA 4-6cm，高cSVA>6cm）对患者进行亚分类，并比较术前和术后3个月的节段性和整体矢状面排列，以确定代偿机制的激活情况。
纳入75例CD患者（平均年龄61.3岁，56%为女性）。CK逐渐增大的患者C0-C2（CL=34°，低CK=37°，高CK=44°，p=0.004）、C2斜率和T1斜率-CL呈逐渐增加趋势（p<0.05）。随着cSVA增加，C2斜率、T1斜率和胸腰段斜率-CL呈逐渐增加趋势（p<0.05），患者通过增加C0-C2（低cSVA=33°，中cSVA=40°，高cSVA=43°，p=0.007）和骨盆倾斜度（低cSVA=14.9°，中cSVA=24.1°，高cSVA=24.9°，p=0.02）进行代偿。术后3个月，随着颈椎对线显著改善，C0-C2有所松弛（39°-35°，p=0.01），且与畸形矫正程度呈正相关。
颈椎排列不齐的患者通过颈椎上半段过度前凸进行代偿，可能是为了维持水平注视。随着cSVA增加，患者还倾向于表现出骨盆后倾增加。手术治疗后，颈椎上半段的代偿作用有所松弛。
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