Does Cervical Alignment Matter? The Effect of 2-level Anterior Cervical Discectomy and Fusion on Sagittal Alignment and Patient-reported Outcomes

Study Design: Retrospective review of prospectively collected data. Objective: This study aimed to determine the change in cervical sagittal balance following 2-level anterior cervical discectomy and fusion (ACDF) and whether the degree of change was associated with improvement in patient-reported outcomes (PROs). Summary of Background Data: Sagittal balance in cervical spine surgery has been recognized as an important surgical goal. However, its influence on clinical outcomes following anterior decompressive procedures remains debatable. Materials and Methods: Patients who underwent primary 2-level ACDF for cervical spondylotic radiculopathy and/or myelopathy were identified from an institutional spine registry. Radiographic measurements were done preoperatively, postoperatively, and at minimum 24 months follow-up. Measurements comprised segmental lordosis (SL), C2-C7 cervical lordosis (CL), C2-C7 sagittal vertical axis, C7 slope (C7S), T1 slope (T1S) and C7 slope minus cervical lordosis (C7S-CL). Disk heights were measured preoperatively and postoperatively. PROs including the Neck Disability Index, Short Form-36, and Visual Analog Scale for neck pain and arm pain were collected preoperatively and at 24 months postoperatively. Results: In total, 90 patients were included. Mean follow-up was 58.6 +/- 22.9 months. Significant improvement in all PROs was achieved at 24 months (P< 0.05). SL was -1.2 +/- 8.2 degrees preoperatively, increased to 5.2 +/- 5.9 degrees postoperatively (P< 0.001), and decreased to 1.2 +/- 6.2 degrees at follow-up (P= 0.005). CL was 8.5 +/- 12.5 degrees preoperatively, increased to 10.8 +/- 12.4 degrees postoperatively (P= 0.018), and maintained at 10.9 +/- 11.2 degrees at follow-up (P= 0.030). Sagittal vertical axis, C7S, T1S, and C7S-CL did not change significantly. Significant increases in disk heights were achieved postoperatively (P< 0.001). Fusion rate was 98.9% at follow-up. PROs were not related to radiologic measurements. Maintaining or increasing CL or SL was not related to a greater degree of improvement in PROs. Conclusions: Two-level ACDF restored segmental and global CL, but changes in cervical sagittal alignment did not correlate with the magnitude of improvement in PROs. Adequate decompression with solid fusion remains fundamental to achieving good clinical outcomes in patients with degenerative cervical disease.

Automated summary

Two-level ACDF can restore segmental and global cervical lordosis, but changes in cervical sagittal alignment do not correlate with the magnitude of improvement in patient-reported outcomes. Maintaining or increasing cervical lordosis or segmental lordosis was not related to a greater degree of improvement in PROs.