European Spine Journal

, Volume 27, Issue 2, pp 416–425 | Cite as

Prospective multi-centric evaluation of upper cervical and infra-cervical sagittal compensatory alignment in patients with adult cervical deformity

  • Subaraman Ramchandran
  • Themistocles S. Protopsaltis
  • Daniel Sciubba
  • Justin K. Scheer
  • Cyrus M. Jalai
  • Alan Daniels
  • Peter G. Passias
  • Virginie Lafage
  • Han Jo Kim
  • Gregory Mundis
  • Eric Klineberg
  • Robert A. Hart
  • Justin S. Smith
  • Christopher Shaffrey
  • Christopher P. Ames
  • International Spine Study Group
Original Article



Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively.


Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10°, cervical scoliosis > 10°, cSVA (C2–C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25°. For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0°, CK-low 0°–10°, CK-high > 10°] and cSVA (cSVA-low 0–4 cm, cSVA-mid 4–6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment.


75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0–C2 (CL = 34°, CK-low = 37°, CK-high = 44°, p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0–C2 (cSVA-low = 33°, cSVA-mid = 40°, cSVA-high = 43°, p = 0.007) and pelvic tilt (cSVA-low = 14.9°, cSVA-mid = 24.1°, cSVA-high = 24.9°, p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0–C2 (39°–35°, p = 0.01) which positively correlated with magnitude of deformity correction.


Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.


Cervical deformity Alignment Upper cervical lordosis Compensation Horizontal gaze 



Funding was provided by DePuy Synthes.

Compliance with ethical standards

IRB approval

IRB approval was obtained prior to the initiation of the study.

Conflict of interest

None of the authors has any potential conflict of interest.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Subaraman Ramchandran
    • 1
  • Themistocles S. Protopsaltis
    • 1
  • Daniel Sciubba
    • 2
  • Justin K. Scheer
    • 3
  • Cyrus M. Jalai
    • 1
  • Alan Daniels
    • 4
  • Peter G. Passias
    • 1
  • Virginie Lafage
    • 5
  • Han Jo Kim
    • 5
  • Gregory Mundis
    • 3
  • Eric Klineberg
    • 6
  • Robert A. Hart
    • 7
  • Justin S. Smith
    • 8
  • Christopher Shaffrey
    • 8
  • Christopher P. Ames
    • 9
  • International Spine Study Group
  1. 1.Department of Orthopedic Surgery, NYU Langone medical CenterNYU Hospital for Joint DiseasesNew YorkUSA
  2. 2.Department of NeurosurgeryJohns Hopkins University Medical CenterBaltimoreUSA
  3. 3.Department of NeurosurgeryUniversity of California San DiegoSan DiegoUSA
  4. 4.Department of Orthopedic SurgeryBrown University Alpert Medical SchoolProvidenceUSA
  5. 5.Department of Orthopedic SurgeryHospital for Special SurgeryNew YorkUSA
  6. 6.Department of Orthopedic SurgeryUniversity of California, DavisSacramentoUSA
  7. 7.Department of Orthopedic SurgeryOregon Health and Science CenterPortlandUSA
  8. 8.Department of NeurosurgeryUniversity of Virginia Medical CenterCharlottesvilleUSA
  9. 9.Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoUSA

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