title: Assessment of Surgical Treatment Strategies for Moderate to Severe Cervical Spinal Deformity Reveals Marked Variation in Approaches, Osteotomies, and Fusion Levels.
abstract: OBJECTIVE
  Although previous reports suggest that surgery can improve the pain and disability of cervical spinal deformity (CSD), techniques are not standardized. Our objective was to assess for consensus on recommended surgical plans for CSD treatment.
  
  
  METHODS
  Eighteen CSD cases were assembled, including a clinical vignette, cervical imaging (radiography, computed tomography/magnetic resonance imaging), and full-length standing radiography. Fourteen deformity surgeons (10 orthopedic, 4 neurosurgery) were queried regarding recommended surgical plans.
  
  
  RESULTS
  There was marked variation in treatment plans across all deformity types. Even for the least complex deformities (moderate midcervical apex kyphosis), there was lack of agreement on approach (50% combined anterior-posterior, 25% anterior only, 25% posterior only), number of anterior (range, 2-6) and posterior (range, 4-16) fusion levels, and types of osteotomies. As the kyphosis apex moved caudally (cervical-thoracic junction/upper thoracic spine) and for cases with chin-on-chest kyphosis, >80% of surgeons agreed on a posterior-only approach and >70% recommended a pedicle subtraction osteotomy or vertebral column resection, but the range in number of anterior (4-8) and posterior (4-27) fusion levels was exceptionally broad. Cases of cervical/cervical-thoracic scoliosis had the least agreement for approach (48% posterior only, 33% combined anterior-posterior, 17% anterior-posterior-anterior or posterior-anterior-posterior, 2% anterior only) and had broad variation in the number of anterior (2-5) and posterior (6-19) fusion levels, and recommended osteotomies (41% pedicle subtraction osteotomy/vertebral column resection).
  
  
  CONCLUSIONS
  Among a panel of deformity surgeons, there was marked lack of consensus on recommended surgical approach, osteotomies, and fusion levels for CSD. Further study is warranted to assess whether specific surgical treatment approaches are associated with better outcomes.
authors.affiliation: Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA. Electronic address: jss7f@virginia.edu.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Smith
authors.affiliation: Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Klineberg
authors.affiliation: Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Shaffrey
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.
authors.forename: Virginie
authors.initials: V
authors.lastname: Lafage
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Schwab
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA.
authors.forename: Themistocles
authors.initials: T
authors.lastname: Protopsaltis
authors.affiliation: University of California San Diego, School of Medicine, San Diego, California, USA.
authors.forename: Justin K
authors.initials: JK
authors.lastname: Scheer
authors.affiliation: Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Tamir
authors.initials: T
authors.lastname: Ailon
authors.affiliation: Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Subaraman
authors.initials: S
authors.lastname: Ramachandran
authors.affiliation: Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Daniels
authors.affiliation: Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California, USA.
authors.forename: Gregory
authors.initials: G
authors.lastname: Mundis
authors.affiliation: Department of Orthopedic Surgery, Washington University, St. Louis, Missouri, USA.
authors.forename: Munish
authors.initials: M
authors.lastname: Gupta
authors.affiliation: Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Hostin
authors.affiliation: Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Vedat
authors.initials: V
authors.lastname: Deviren
authors.affiliation: Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Eastlack
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Passias
authors.affiliation: Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: D Kojo
authors.initials: DK
authors.lastname: Hamilton
authors.affiliation: Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Hart
authors.affiliation: Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
authors.forename: Douglas C
authors.initials: DC
authors.lastname: Burton
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA.
authors.forename: Shay
authors.initials: S
authors.lastname: Bess
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
mesh_terms: D000368:Aged; D032921:Consensus; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000069471:Neurosurgeons / Q000592:standards*; D000072161:Orthopedic Surgeons / Q000592:standards*; D010027:Osteotomy / Q000379:methods*; D012720:Severity of Illness Index; D013121:Spinal Curvatures / Q000000981:diagnostic imaging* / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*
keywords: Cervical; Deformity; Fusion; Kyphosis; Osteotomy; Spine; Surgery