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Journal of Craniovertebral Junction and Spine
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Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 306-310

The impact of the lower instrumented level on outcomes in cervical deformity surgery

1 Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
2 Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
3 Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
4 Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA

Correspondence Address:
Peter Gust Passias
Department of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center, New York Spine Institute, Orthopaedic Hospital – NYU School of Medicine, 301 East 17th St, New York 10003, NY
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvjs.jcvjs_23_21

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Background: The lower instrumented vertebrae (LIVs) in cervical deformity (CD) constructs may have varying effects on patient outcomes that are still poorly understood. Objective: The objective of the study is to compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver (PD). Methods: Patients who met radiographic criteria for CD were included in the study. Patients were stratified by PD of deformity: cervical (C) through AMES classification (TS-CL >20 or cervical sagittal vertical axis >40) and thoracic (T) through hyper/hypokyphosis (TK) from T4-T12 (60 < TK < 40). Patients were further stratified by LIV in relation to curve apex (above/below). Univariate and multivariate analyses identified group differences in postoperative health-related quality-of-life and distal junctional kyphosis (DJK) (>10° LIV and LIV + 2) rate up to 1 year. Results: Sixty-two patients were analyzed. Twenty-one patients had a C-PD and 41 had a T-PD by definition. 100% of C-PDs had LIVs below CL apex, while 9.2% of T-PDs had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. By 1 year, C patients trended lower Neck Disability Index (NDI) (21.9 vs. 29.0, P = 0.245), lower numeric rating scales neck pain (4.2 vs. 5.1, P = 0.358), and significantly higher EuroQol five-dimensional questionnaire Visual Analog Scale (69.2 vs. 52.4, P = 0.040). When T patients with LIVs below TK apex were excluded, remaining T patients with LIV above apex had significantly higher 1-year NDI than C patients (37.5 vs. 21.9, P = .05). T patients also trended higher rates of postoperative DJK than C (19.5% vs. 4.8%, P = 0.119). Conclusions: Stopping before apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of DJK.

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