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. 2024 Jun 15;32(12):e585-e595.
doi: 10.5435/JAAOS-D-23-00565. Epub 2024 Apr 5.

Cervical Sagittal Alignment and Related Factor Analysis and Prediction Model in Patients Undergoing Revision Surgery After Anterior Cervical Fusion

Manini Daudi Romani  1 , Hong-Qi Zhang, Qi-Le Gao, Shao-Hua Liu, Ang Deng
Affiliations

Cervical Sagittal Alignment and Related Factor Analysis and Prediction Model in Patients Undergoing Revision Surgery After Anterior Cervical Fusion

Manini Daudi Romani et al. J Am Acad Orthop Surg. .

Abstract

Introduction: Patients with myelopathy or radiculopathy commonly undergo anterior cervical fusion surgery (ACFS), which has a notable failure rate on occasion. The goal of this study was to compare revision and nonrevision surgery patients in cervical sagittal alignment (CSA) subsequent to ACFS; additionally, to identify the best CSA parameters for predicting clinical outcome after ACFS; and furthermore, to create an equation model to assist surgeons in making decisions on patients undergoing ACFS.

Methods: The data of 99 patients with symptomatic cervical myelopathy/radiculopathy who underwent ACFS were analyzed. Patients were divided into group A (underwent revision surgery after the first surgery failed) and group B (underwent only the first surgery). We measured and analyzed both preoperative and postoperative CSA parameters, including C2 slope, T1 slope, cervical lordosis C2-C7 (CL), C2-C7 sagittal vertical axis (C2C7 SVA), occiput-C2 lordosis angle (C0-C2), and chin brow vertical angle, and we further computed the correlation between the CSA parameters and created a prediction model.

Results: The (T1S-CL)-C2S mismatch differed significantly between groups A and B ([9.95 ± 9.95] 0 , [3.79 ± 6.58] 0 , P < 0.05, respectively). A significant correlation was observed between C2 slope and T1CL in group B relative to group A postoperatively (R 2 = 0.42 versus R 2 = 0.09, respectively). Compared with group B, patients in group A had significantly higher C2C7SVA values, more levels of fusion, and more smokers. The sensitivity, specificity, accuracy, and discrimination of the model were, respectively, 73.5%, 84%, 78.8%, and 85.65%.

Conclusion: The causes of revision surgery in cervical myelopathic patients after anterior cervical corpectomy and fusion/anterior cervical diskectomy and fusion are multifactorial. (T1S-CL)-C2S mismatch and high C2C7SVA are the best cervical sagittal parameters that increase the odds of revision surgery, and the effect is more enhanced when comorbidities such as smoking, low bone-mineral density, and increased levels of fusion are taken into account.

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Figures

Figure1
Figure1
Diagram showing the description of radiographic measurement. A= C2-C7 sagittal vertical axis was measured as the distance between the C2 plumb line and the posterior upper end plate of C7 vertebra. B= Cervical lordosis (C2-C7) was measured as the angle between the inferior end plate of C2 vertebra and the inferior end plate of C7 vertebra. C= C2-slope was measured as the angle between the lower end plate of C2 and the horizontal plane, and T1-slope was measured as the angle between the superior end plate of T1 and the horizontal plane. D= Chin brow vertical angle (CBVA) was measured as the angle formed by a vertical line and a line connecting the most anterior aspect of the forehead and chin. Occiput-C2 lordosis angle (C0-C2 angle) was measured as the angle subtended between the McGregor line and the inferior end plate of C2.
Figure 2
Figure 2
A scatter plot depicting the association between C2 slope (C2S) and T1S-CL preoperatively and postoperatively in the revision and nonrevision groups.
Figure 3
Figure 3
ROC curve of the 5-predictor model among revision and nonrevision surgery patients.
Figure 4
Figure 4
ROC curve for the cervical sagittal alignment predictor model ([T1S-CL]-C2S, C2C7SVA) among revision and nonrevision surgery patients postoperatively.
Figure 5
Figure 5
Radiographs of a 45-year-old man (A, B, and C) who underwent anterior cervical corpectomy and fusion) secondary to cervical disk herniation at C4/C6. Immediate postoperative (B) T1S-CL versus C2 slope was 5.40; after 3 years, the same patient developed disk herniation at C3/C4 and underwent revision surgery. D and E depicts a 54-year-old woman who underwent ACCF at C4/C6 for a herniated cervical disk. The immediate postoperative (B) mismatch between T1S-CL and C2S was 0.70, and more than 3 years of follow-up revealed no recurrence.
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