title: Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy.
abstract: OBJECTIVE
  Sagittal spinopelvic malalignment is a significant cause of pain and disability in patients with adult spinal deformity. Surgical correction of spinopelvic malalignment can result in compensatory changes in spinal alignment outside of the fused spinal segments. These compensatory changes, termed reciprocal changes, have been defined for thoracic and lumbar regions but not for the cervical spine. The object of this study was to evaluate postoperative reciprocal changes within the cervical spine following lumbar pedicle subtraction osteotomy (PSO).
  
  
  METHODS
  This was a multicenter retrospective radiographic analysis of patients from International Spine Study Group centers. Inclusion criteria were as follows: adults (>18 years old) with spinal deformity treated using lumbar PSO, a preoperative C7-S1 plumb line greater than 5 cm, and availability of pre- and postoperative full-length standing radiographs.
  
  
  RESULTS
  Seventy-five patients (60 women, mean age 59 years) were included. The lumbar PSO significantly improved sagittal alignment, including the C7-S1 plumb line, C7-T12 inclination, and pelvic tilt (p <0.001). After lumbar PSO, reciprocal changes were seen to occur in C2-7 cervical lordosis (from 30.8° to 21.6°, p <0.001), C2-7 plumb line (from 27.0 mm to 22.9 mm), and T-1 slope (from -38.9° to -30.4°, p <0.001). Ideal correction of sagittal malalignment (postoperative sagittal vertical alignment < 50 mm) was associated with the greatest relaxation of cervical hyperlordosis (-12.4° vs -5.7°, p = 0.037). A change in cervical lordosis correlated with changes in T-1 slope (r = -0.621, p <0.001), C7-T12 inclination (r = 0.418, p <0.001), T12-S1 angle (r = -0.339, p = 0.005), and C7-S1 plumb line (r = 0.289, p = 0.018). Radiographic parameters that correlated with changes in cervical lordosis on multivariate linear regression analysis included change in T-1 slope and change in C2-7 plumb line (r(2) = 0.53, p <0.001).
  
  
  CONCLUSIONS
  Adults with positive sagittal spinopelvic malalignment compensate with abnormally increased cervical lordosis in an effort to maintain horizontal gaze. Surgical correction of sagittal malalignment results in improvement of the abnormal cervical hyperlordosis through reciprocal changes.
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Smith
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Shaffrey
authors.forename: Virginie
authors.initials: V
authors.lastname: Lafage
authors.forename: Benjamin
authors.initials: B
authors.lastname: Blondel
authors.forename: Frank
authors.initials: F
authors.lastname: Schwab
authors.forename: Richard
authors.initials: R
authors.lastname: Hostin
authors.forename: Robert
authors.initials: R
authors.lastname: Hart
authors.forename: Brian
authors.initials: B
authors.lastname: O'Shaughnessy
authors.forename: Shay
authors.initials: S
authors.lastname: Bess
authors.forename: Serena S
authors.initials: SS
authors.lastname: Hu
authors.forename: Vedat
authors.initials: V
authors.lastname: Deviren
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
mesh_terms: D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010027:Osteotomy / Q000379:methods*; D004856:Postural Balance; D011859:Radiography; D012189:Retrospective Studies; D013121:Spinal Curvatures / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D016896:Treatment Outcome