SPINE Volume 37, Number 22S, pp S75–S84

©2012, Lippincott Williams & Wilkins

ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE

Does Postsurgical Cervical Deformity Affect the

Risk of Cervical Adjacent Segment Pathology?
A Systematic Review
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h

Mitchell A. Hansen, BSc, MBBS, Grad Dip Sc, PhD, FRACS,* Han Jo Kim, MD,† Ellen M. Van Alstyne, MS,‡
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023

Andrea C. Skelly, MPH,PhD,‡ and Michael G. Fehlings, MD, PhD, FRCSC*§

ASP after posterior cervical surgery. Three studies provided data

Study Design. Systematic review.
from which unadjusted RRs and 95% confidence intervals could be
Objective. To assess whether the presence or magnitude of
calculated. These studies showed an increased risk of ASP associated
postsurgical malalignment in the coronal (scoliosis) or sagittal plane
with malalignment (RR, 2.24 [95% confidence interval, 1.40–3.56];
(kyphosis/spondylolisthesis) affects the risk of cervical adjacent
RR, 2.40 [1.33, 4.33]; RR, 1.32 [0.96, 1.81]). No study evaluating
segment pathology (ASP).
coronal imbalance as a risk factor for cervical ASP was found and
Summary of Background Data. ASP occurs in selected patients
none reported on clinical ASP.
who have undergone surgical treatment for cervical spondylosis.
Conclusion. There is low-grade evidence from 3 published studies
The reasons are multifactorial; however, postsurgical alignment may
that postsurgical sagittal imbalance may increase the risk for cervical
play a key role. To elucidate this issue, a systematic review of the
radiological ASP.
literature was undertaken.
Consensus Statement
Methods. A systematic search in PubMed was conducted for
An attempt should be made to maintain or restore cervical lordosis
literature published in English language through February 15, 2012.
in surgical intervention for cervical disorders.
Studies in adults, designed to evaluate postsurgical sagittal or coronal
Strength of Statement: Weak
malalignment as risk factors for radiographical or clinical ASP, were
Key words: cervical spondylosis, degenerative disc disease, spine
sought. Studies of pediatric or oncological patients were excluded.
surgery, sagittal alignment. Spine 2012;37:S75–S84
Case reports, case series, and patient populations of less than 10
patients were also excluded. Unadjusted risk ratios (RRs) and 95%
confidence intervals were calculated to evaluate the association

between alignment and the risk for developing ASP.
Results. The search yielded 338 citations. Of that, 311 were
excluded at the title and abstract level. Of the 27 selected for full-
text review, 5 poor-quality retrospective studies met the inclusion
criteria and described sagittal imbalance measures as risk factors
for radiological ASP after anterior surgery. No studies examined
From the *Krembil Neuroscience Center, Spinal Program, University Health
Network, University of Toronto, Toronto, Ontario, Canada; †Washington
University School of Medicine, Department of Orthopedic Surgery, St.
Louis, MO; ‡Spectrum Research, Inc, Tacoma, WA; and §Neurosurgery, and
Neuroscience Program, University of Toronto, Toronto, Ontario, Canada.
Acknowledgment date: April 27, 2012. First revision date: June 19, 2012.
Second revision date: July 30, 2012. Acceptance date: August 1, 2012.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Supported by AOSpine North America, Inc. Analytic support for this work
was provided by Spectrum Research, Inc., with funding from the AOSpine
North America.
No benefits in any form have been or will be received from a commercial
party related directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Michael G. Fehlings, MD,
PhD, FRCSC, FACS, The Toronto Western Hospital, University Health Network,
Room 4W-449, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada; E-mail:
Michael.Fehlings@uhn.on.ca
DOI: 10.1097/BRS.0b013e31826d62a6
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C
ervical spondylosis may cause axial neck pain, radicu-
lopathy, or myelopathy. Decompression of the cervical
spine is a common operation done to alleviate these
symptoms.1 The procedure involves decompression of the
foramina to relieve the symptoms. After the decompression
has been completed, arthrodesis, either anteriorly or posteri-
orly, or anterior disc arthroplasty is often undertaken.2 Once a
segment has been fused, the adjacent levels must compensate
for the loss of motion at the fusion site. Degeneration at the
adjacent site may then be multimodal in pathogenesis. Pro-
gression of this degeneration at the adjacent levels has been
attributed to a variety of things including a greater range
of movement, loss of disc nutrition due to endplate stress,
reduced intervertebral disc height, instability, and greater
stress on fewer joints.3 Arthroplasty has been purported to
circumvent some of these causes of adjacent-level disease.
However, whether the joint(s) is/are fused or motion spared,
sagittal and coronal alignment has been implicated in adja-
cent-segment pathology (ASP). This is especially important in
revision surgery for construct failure for iatrogenic, congeni-
tal, or advanced degenerative disc disease.4
Whether degree of lordosis, level of fusion, or continuing
sagittal alignment significantly contributes to ASP is unclear.
www.spinejournal.com S75

BRS205230.indd S75 9/25/12 1:49 AM

 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al

This article will systematically review the evidence for cervi-

cal malalignment as a risk factor for cervical ASP and present TABLE 1. Inclusion and Exclusion Criteria
a case illustration to discuss some of the important clinical Inclusion Exclusion
concepts related to this topic.
Patient Adult patients who have • Pediatric
As noted elsewhere in this focus issue, there is a lack of
had surgery for any of the • Tumor
precision regarding the terminology used to describe these following: • Animal or cadaver
entities. The term ASP is proposed as an umbrella term to • Cervical spondylosis • Thoracic or
refer to the breadth of clinical and/or radiographical changes • Cervical trauma lumbar
at adjacent motion segments that developed subsequent to a • Cervical radiculopathy
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h

previous spinal intervention. Under this umbrella, radiologi- • Cervical deformity

cal ASP (RASP) and clinical ASP (CASP) are then used to cat- • Kyphosis
egorize radiographical features (e.g., degenerative changes on
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023

• Adjacent segment
magnetic resonance imaging [MRI]) and clinical manifesta- degeneration in the
tions (e.g., new radiculopathy), respectively. The term adja- cervical spine
cent segment disease is retained for describing search methods Prognostic • Presence and/or degree
and definitions used by authors of included articles. factors of postsurgical sagittal
The primary question to be assessed in this systematic malalignment (kyphosis/
review is: Does the presence or magnitude of postsurgi- loss of lordosis) of fused
and/or adjacent segments
cal malalignment in the coronal (scoliosis) or sagittal plane
• Presence and/or degree
(kyphosis/lordosis) affect the risk of cervical ASP?
of postsurgical coronal
malalignment of fused
MATERIALS AND METHODS and/or adjacent segments
Outcome • Cervical ASD • Range of motion
Electronic Literature Search (radiographical or • Kinematics
A systematic search in PubMed was conducted for literature symptomatic) • Adjacent segment
published through February 15, 2012. The search results ossification
were limited to human studies published in the English lan- • Disc height
guage. Reference lists of key articles were also systematically
checked to identify additional eligible articles. General search Study • Cohort studies evaluating • Animal or
design the effect of sagittal and/ biomechanical
terms included alignment, malalignment, kyphosis, lordosis, or coronal alignment on studies
fusion, adjacent segment degeneration or disease, and scolio- frequency of cervical ASD • Case series n < 10
sis. The focus was on identifying studies designed to evaluate
ASD indicates adjacent segment disease or adjacent segment deterioration.
postsurgical sagittal or coronal malalignment as risk factors
for either RASP or CASP. Two individuals independently eval-
uated potentially relevant studies against the inclusion criteria
that were set a priori (Table 1). Studies, which evaluated adult
patients who have had surgery for cervical degenerative disc Supplemental Digital Material, Supplemental Digital Content
disease, with or without radiculopathy and/or myelopathy, or 1, available at http://links.lww.com/BRS/A700).
other cervical spine pathologies, and studies that evaluated
risk of adjacent segment disease in relation to the sagittal or Study Quality and Overall Strength of
coronal alignment of the cervical spine either at or adjacent Body of Literature
to the level of intervention, were considered for inclusion Level of evidence ratings were assigned to each article inde-
(Figure 1). Studies of pediatric or oncological patients were pendently by 2 reviewers (E.M.V., A.C.S.) using criteria set by
excluded. Studies reporting on risk factors for malalignment The Journal of Bone & Joint Surgery, American Volume,5 for
were excluded if they did not also report risk of ASP. Case prognostic studies and modified to delineate criteria associ-
reports, case series, and patient populations of less than 10 ated with methodological quality as described elsewhere6 (see
patients were also excluded. Additional information may be Supplemental Digital Material, Supplemental Digital Content 1,
found in the supplemental digital material (see Supplemental available at http://links.lww.com/BRS/A700 for individual
Digital Material, Supplemental Digital Content 1, available at study ratings). The overall body of evidence with respect to
http://links.lww.com/BRS/A700). each clinical question was determined on the basis of pre-
cepts outlined by the Grades of Recommendation Assess-
Data Extraction ment, Development, and Evaluation working group7 and rec-
From the included articles, the following data were extracted: ommendations made by the Agency for Healthcare Research
patient demographics, inclusion and exclusion criteria, and Quality.8 Risk of bias was evaluated during the individual
follow-up duration and the rate of follow-up, outcomes study evaluation described earlier in the section “Study Qual-
assessed, risks (%) of ASP, and information about post- ity.” This system, which derives a strength-of-evidence grade
surgical malalignment as a risk factor for cervical ASP (see for each outcome or clinical question of “high,” “moderate,”
S76 www.spinejournal.com October 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BRS205230.indd S76 9/25/12 1:49 AM

 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE
1. Total citations from search
(n = 338)
2. Title/abstract exclusion
(n = 311)
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
3. Retrieved for full-text evaluation
(n = 27)
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023
4. Excluded at full–text review
(n = 22)
5. Publications included
(n = 5)
Figure 1. Flowchart showing results of literature search.
“low,” or “insufficient,” is described in further detail in the
methods article for this focus issue.6 The supplemental dig-
ital material contains the details of how we arrived at the
strength of evidence for each key question (see Supplemental
Digital Material, Supplemental Digital Content 1, available
at http://links.lww.com/BRS/A700).
Data Analysis
Where the data were available, the risk (cumulative incidence)
of ASP in studies of malalignment was reported. Data were
summarized but were not pooled between studies due to the
limited number of studies available and the heterogeneity of
malalignment definitions, patient populations, and outcomes.
To evaluate the effect of malalignment as a risk factor for
ASP, we calculated the unadjusted risk ratios (RRs) with cor-
responding confidence intervals and P values where data were
available. RRs more than 1.0 indicated an increased risk of
ASP associated with the factor, whereas those that were less
than 1.0 indicated a decreased risk. If the 95% confidence
interval included the value of 1.0, the association was deemed
not statistically significant. All calculations were performed
using Stata 9.0 (StataCorp LP, College Station, TX).9
Clinical Recommendations and Consensus Statements
Clinical recommendations or consensus statements were made
through a modified Delphi approach by applying the Grades
of Recommendation Assessment, Development, and Evalua-
tion/Agency for Healthcare Research and Quality criteria that
impart a deliberate separation of the strength of the evidence
(i.e., high, moderate, low, or insufficient) from the strength
of the recommendation. Where appropriate, recommenda-
tions or statements “for” or “against” were given “strong” or
“weak” designations based on the quality of the evidence, the
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205230.indd S77
Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
balance of benefits/harms, and values and patient preferences.
In some instances, costs may have been considered. A more
thorough description of this process can be found in the Focus
Issue methods article.6
RESULTS
Study Selection
The search strategy yielded a total of 338 citations, of which
311 could be eliminated on the basis of the title or abstract;
full text was retrieved for 27 studies; and of these there
were 5 that provided data for risk of ASP in the context of
malalignment after cervical spine surgery.10–14 All reported
on RASP. No studies reported on CASP or additional inter-
vention to address ASP. Each study used different definitions
for malalignment, precluding any pooling of data. No study
examined the effect of malalignment on ASP after posterior
surgery. No study examined the effect of malalignment in the
coronal plane on ASP after any surgery.
Does the Presence or Magnitude of Postsurgical
Malalignment in the Coronal (Scoliosis) or
Sagittal Plane (Kyphosis/Lordosis) Affect the
Risk of Cervical ASP?
Table 2 summarizes characteristics of included studies. Study
populations tended to be primarily male and most had
undergone surgery for degenerative cervical disc disease. The
reported follow-up times ranged from 1.5 to 23 years and
the follow-up in these studies was either low or not calcu-
lable. All were retrospective and considered level III evidence.
Additional information on included studies and their qual-
ity assessment is contained in the supplemental digital mate-
rial (see Supplemental Digital Material, Supplemental Digital
Content 1, available at http://links.lww.com/BRS/A700).
The overall risk (i.e., cumulative incidence) of RASP ranged
from 17% to 75% in 4 studies.10–13 The definition of ASP was
primarily based on radiographical or MRI findings. Only 1
study attempted to include symptomatology as part of the
ASP definition.11 Overall risk could not be calculated from the
information provided regarding patients in the fifth study.14
Three studies provide data from which unadjusted RRs
and 95% confidence intervals could be calculated.10,12,13 In 2
of the 3 studies, the risk of RASP associated with malalign-
ment was approximately 2-fold with the third study showing
a slightly lower risk, which failed to reach statistical signifi-
cance (Figure 2). Details of these studies are described below.
Faldini et al10 defined lordotic (normal alignment) patients
as those with postoperative sagittal segmental alignment
(SSA) of more than 0°, and kyphotic as SSA 0° or less; in this
study, 27% (n = 18/66) of persons with lordosis and 61% (n
= 25/41) of those with kyphosis developed RASP. The SSA
was measured by using the angle between a line parallel to
the upper border of the vertebral body proximal to the disc
space involved and a line parallel to the lower border of the
underlying vertebral body for the fused vertebrae. A tendency
to kyphosis in postoperative SSA was determined to correlate
with the development of RASP (r = –0.428; P < 0.001),
www.spinejournal.com S77
9/25/12 1:49 AM
 CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h

S78
TABLE 2. Characteristics of Included Studies
Prognostic

BRS205230.indd S78
Authors (yr) Demographics Purpose Inclusion/Exclusion Follow-up Factors Outcomes
10
Faldini et al n = 107 To determine whether Inclusion: One level cervical disc Median 16 yr Malalignment: ASD defined as: Standard radio-
Retrospective M: NR postoperative sagittal disease between C4–C7 (10–23) Group A graphs; parameters of Kellgren
cohort segmental alignment can Discectomy and single-level % f/u: (SSA ≤ 0°) and Lawrence: grade 0, definite
Age range: 35–55 yr
be used to predict adjacent anterior cervical fusion by NR Group B absence of degenerative changes
One level cervical
level degeneration. Cloward procedure grade 1, doubtful presence of de-
disc disease from (SSA > 0°)

www.spinejournal.com
Exclusion: NR generation grade 2, degeneration
C4–C7
present but of minimal severity
grade 3, moderate degeneration
grade 4, severe degeneration
Ishihara et al11 n = 112 To study the incidence and Inclusions: Intervertebral disc Mean 9.4 yr Mean degrees ASD defined as: Presence of both
Retrospective M: 66% prevalence of symptomatic herniation and cervical (2–19) % f/u: alignment new radiculopathy or myelopathy
cohort adjacent segment disease spondylosis 70% preoperative symptoms referable to the adjacent
Mean age 51 yr
after anterior cervical Anterior cervical discectomy and Mean degrees level on MRI or myelography;
(31–70)
interbody fusion, and to arthrodesis using autogeneous alignment evaluated by criteria of Hilibrand
Intervertebral disc analyze potential prognostic iliac-crest graft without plate et al4: intervertebral disc narrowing
after fusion
herniation and factors, including lordosis of >2 mm compared with
fixation; 1-level fusion n = 66,
cervical spondylosis or kyphosis before and after adjacent segments, osteophyte
2-level fusion n = 44, 3-level
fusion. fusion n = 2 formation of >2 mm, anterior or
Exclusions: NR posterior slip of >2 mm

Katsuura n= 42 To study whether cervical Inclusions: Anterior cervical Mean 9.8 yr Alignment: ASD defined as: At least one of
et al12 M: 81% malalignment (kyphotic fusion, no instrumentation, for (5–22) % f/u: Straight the following criteria met in
Retrospective deformity) after anterior degenerative disorders, cervical 45% Lordosis comparison with preoperative
Mean age: 50.2 yr
cohort fusion was a prognostic spondylosis, or cervical disc Kyphosis radiographical findings: evident
(SD, 9.4)
factor for progression herniation Sigmoid intervertebral disc space
Degenerative disorders, of adjacent segment narrowing newly developed
Single-level n = 232-level n = 17
cervical spondylo- degeneration. instability >3mm on flexion-
3-level n = 2
sis, or cervical disc extension radiographs vertebral
ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE

herniation, single, 2-, Exclusions: NR

posterior spur formation
or 3-level
Kulkarni n = 44 To study potential prognostic Inclusions: Central cervical Mean 1.5 yr Kyphotic ASD defined as: MRI evaluation of
et al13 M: 98% factors for the development corpectomy and fusion; 1-level (0.8–4)% f/u: NR alteration adjacent segments for indentation
Retrospective of symptomatic adjacent- n = 11; 2-level n = 33 Alignment of the thecal sac, disc height,
Mean age: 46 yr
cohort segment degeneration Exclusions: NR maintained sagittal functional diameter of the
(31–66)
after cervical corpectomy, spinal canal
including the changes in the
sagittal alignment.
Matsumoto n = 64 To study the incidence Inclusions: 1- or 2-level Mean 12.1 yr % Group A ASD defined as: MRI evaluation
et al14 M: 75% of adjacent segment noninstrumented ACDF for disc f/u: 62% (kyphosis < for degenerative findings; grading
Retrospective degeneration 10 yr after hernia or spondylosis 5°) system used to evaluate: decrease
Mean age
cohort ACDF and compare with Preoperative MRI Group B in signal intensity of intervertebral
47.3 yr (range NR)
healthy volunteers, including No history of surgery (kyphosis ≥ disc posterior disc protrusion disc
Disc hernia or
analysis of kyphotic angle of 5°) space narrowing foraminal stenosis

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
spondylosis Exclusions: Revision surgery for
fusion as a prognostic factor. (evaluated on right and left sides)
ASD after index surgery
ACDF indicates anterior cervical discectomy and fusion; ASD, adjacent segment disease or adjacent segment deterioration; f/u, follow-up; MRI, magnetic resonance imaging; NR, not reported or described; SSA,
sagittal segmental alignment.

October 2012
Risk of Cervical ASP? • Hansen et al
Does Postsurgical Cervical Deformity Affect the

9/25/12 1:49 AM
 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023
Figure 2. Summary of risk ratios for the association between postoperative malalignment and cervical adjacent segment pathology. SSA indicates
sagittal segmental alignment.
as did a tendency to kyphosis of SSA at last follow-up (r =
–0.543; P < 0.001). It is not clear at what point postopera-
tively measurements were taken. The sagittal alignment of
the cervical spine was calculated from the line parallel to the
upper border of the C2 vertebral body and the line parallel to
the lower border of the C7 vertebral body; it is also positive
in case of lordotic alignment and negative when kyphotic. No
correlation was demonstrated between the postoperative sag-
ittal alignment of the cervical spine and the development of
RASP, or between the sagittal alignment of the cervical spine
at last follow-up and RASP. All data were obtained from
radiographs and patients’ files, without recalling any patients
at the time of this study. There were 271 patients who under-
went surgery during the study, but 128 were excluded due
to other pathologies present, age more than 65 years at last
follow-up, or incomplete radiographs with all vertebral bod-
ies from C2–C7 clearly visible; a further 36 patients did not
have a minimum follow-up of 10 years and thus were not
available for analysis.
Katsuura et al12 divided patients into 4 groups based
on the alignment of the cervical spine, those with lordotic
(normal) alignment, and those with malalignment being
described as straight, kyphotic, or sigmoid. In this study,
33% (n = 18/33) of those with lordosis developed RASP,
compared with patients with straight alignment (100%;
n = 3/3), kyphotic (88%; n = 7/8), or sigmoid alignment
(50%; n = 2/4). These alignments for the cervical spine
were determined from the overall shape and angles formed
from tangent lines to the posterior edges of C2–C7. The SSA
was determined from the angle formed by the upper plane
and the lower plane of the fused segment. On the basis of
multiple regression analysis, the preoperative alignment of
the cervical spine was associated with a higher incidence of
RASP (P < 0.0001), and the postoperative SSA could be a
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205230.indd S79
Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
possible determinant (P = 0.0671). Data were available for
42 of 93 patients, who agreed to return to participate in the
study, and who had a follow-up of more than 5 years from
surgery. To calculate the RR, those with any alignment of the
cervical spine other than lordosis were compared with those
who had lordosis.
Kulkarni et al13 described their patients as those for whom
alignment of the cervical spine was maintained, of which 67%
developed RASP, versus those with kyphotic alteration, 88%.
Kyphotic alteration was defined as a lordotic spine that became
straight or kyphotic, or a straight spine that became kyphotic,
as measured on lateral cervical radiographs obtained before
surgery and at follow-up. The classification was determined
by a line drawn from the posterior of the inferior endplate of
C2 to C7; the spine was classified as lordotic if all vertebrae
between these points were ventral to the line, as straight if any
touched the line, and as kyphotic if 1 or more intersected the
line. No statistical association between the risk of RASP and
this classification of malalignment was seen.
The remaining 2 studies provided limited information regard-
ing the risk of RASP related to postsurgical malalignment.
Ishihara et al11 (n = 112) compared the mean fusion align-
ment between those who were classified as having RASP and
those who did not, with lordosis represented by a positive
number of degrees and kyphosis as a negative number of
degrees. Alignment was measured radiographically for the
angle from C2 to C7 on a lateral radiograph taken in the
standing position. Among those with ASP, the mean degree
of fusion alignment (n = 19) was 1.27° ± 2.82°, and among
those without ASP (n = 93), –1.00° ± 6.78°, and there was no
statistically significant association (P = 0.217). The large SDs
call the stability of these measurements into question.
Matsumoto et al14 reported MRI results related to degen-
erative disease for 64 individuals who had undergone anterior
www.spinejournal.com S79
9/25/12 1:49 AM
 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al

cervical discectomy and fusion (ACDF). They describe
different categories of degenerative changes seen on MRI
relative to “fusion in kyphosis” of 5° or more or less than
5°. There were smaller percentages of patients with decreased
signal intensity, disc space narrowing, or foraminal stenosis
among those with less kyphosis (<5°), but more patients in
this group had posterior disc protrusion. However, it seems
that individuals could have findings in more than 1 category.
It was not possible to determine the proportion of individuals
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
C4–C5 changed from –12º to 3º. This in turn led to changes
at C3–C4 from –3º to 16º and at C5–C6 from –2º to 3º. There
was no evidence of RASP or CASP in follow-up to 3 years
postsurgery.
Case Study 2
ZG was 44 year old when he presented with cervical myelopa-
thy after a fall off a mountain bike months earlier. His imaging
demonstrated spondylosis at C5–C6 and C6–C7 and evidence

in each group that was considered to have RASP. The authors of degenerative disc disease at all levels in the cervical spine
state that only the number of fused levels was significantly (Figure 4). The C2–C7 Cobb angle was 29º, at C2–C3 6º, at
associated with development of RASP. C3–C4 –5º, at C4–C5 –3º, and at C5–C7 18º. He underwent
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023

a C5–C6 and C6–C7 ACDF. Postoperatively his C2–C7 Cobb

Evidence Summary
The overall strength of evidence on postsurgical sagittal
malalignment as a risk factor for RASP after anterior proce-
dures in the cervical spine was low, indicating that we have
low confidence that the evidence reflects the true effect. Fur-
ther research is likely to change our confidence in the effect
estimate and it is likely to change the estimate of effect given
that the evidence either is unavailable or does not permit a
conclusion. No studies on CASP or the influences of coronal
malalignment or posterior procedures on the development
of ASP were identified, thus the strength of evidence was
insufficient (Table 3).
Case Study 1
PW was 41 year old when she presented with significant right
shoulder and lateral arm pain. On examination, she had 4+/5
power on shoulder abduction, hyper-reflexic, and a positive
Hoffman sign on the right. The imaging demonstrated a disc
extrusion at C4–C5 with slight right eccentricity (Figure 3).
She underwent a C4–C5 ACDF to treat her pathology with
good result and complete resolution of her symptoms when
reviewed at follow-up by 6 weeks. In our hands, the ACDF
procedure requires placement of the graft in the interbody
space ventrally, to distract the space open and restore ventral
height, and therefore the trend toward lordosis. Preopera-
tively her C2–C7 Cobb angle was 20º and at postoperative
follow-up 3 years later, 18º. There was a significant trend to
lordosis at the segmental level. The angle at the fusion level at
angle was 12º, at C2–C3 –3º, C3–C4 –10º, C4–C5 –9º, and
the angle of the fusion, C5–C7, 14º. There was thus a reduc-
tion of 4º with the fusion at C5–C7. The spine was made
more kyphotic at adjacent segments and overall alignment
less lordotic. Four years later, he presented with neck pain
and myelopathy shortly after a fall. Imaging demonstrated
RASP to the previous C5–C7 ACDF at C4–C5. His C2–C7
Cobb angle was 6º, at C2–C3 –5º, at C3–C4 –13º, at C4–C5
–6º, and the angle of the fusion, as expected, remained at 14º.
This case demonstrates the complexity of the management of
cervical spondylosis. Although segmental alignment was rela-
tively maintained, global alignment was not preserved. The
adjacent segments thus became more kyphotic and it would
seem that this contributed to the development of CASP. A
C4–C5 ACDF was undertaken to address the ASP. The sur-
gery paid particular attention to increasing the ventral height
of the C4–C5 disc. After the revision surgery, the adjacent
segments trended back toward lordosis. The Cobb angle for
C2–C7 became 14º, C2–C3 –2º, C3–C4 –1º, and the angle of
the fusion of C4–C7 13º. There was no evidence of ASP at 18
months postoperatively.
DISCUSSION
This article systematically reviews the available published evi-
dence on the possible influence of alignment on the develop-
ment of ASP. The overall strength of evidence to address this
question with regard to sagittal malalignment was rated as
low, with only 5 poor-quality retrospective studies (level of

TABLE 3. Evidence Summary

Strength of Upgrade Downgrade
Evidence Conclusions/Comments Baseline (Levels) (Levels)
Question: Does the presence or magnitude of postsurgical malalignment in the coronal (scoliosis) or sagittal plane (kyphosis/lordosis)
affect the risk of cervical ASD?
Sagittal malalignment Low Limited data from 3 LoE III retrospective cohorts Low No No
suggest that risk of ASD may be increased when
malalignment occurs postoperatively
Coronal malalignment Insufficient No studies found Insufficient NA NA
Baseline quality: High, majority of article level I/II; Low, majority of articles level III/IV.
Upgrade: Large magnitude of effect (1 or 2 levels); dose-response gradient (1 level).
Downgrade: Inconsistency of results (1 or 2 levels); indirectness of evidence (1 or 2 levels); imprecision of effect estimates (1 or 2 levels).
ASD indicates adjacent segment disease; NA, not applicable.

S80 www.spinejournal.com October 2012

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BRS205230.indd S80 9/25/12 1:49 AM

 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023

Figure 3. (A) Initial T2-weighted sagittal magnetic resonance image (MRI) demonstrating the C4–C5 disc extrusion. (B) Postoperative T2-weighted
sagittal MRI demonstrating decompression of the spinal cord at C4–C5. (C) Preoperative lateral cervical radiograph demonstrating the sagittal
alignment. C2–C7 Cobb angle was –20º, C3–C4 –3º, angle of C3–C5 –12º, and C5–C6 −2º. (D) Lateral cervical radiograph taken 3 years postop-
eratively. Sagittal alignment has become more lordotic at the segmental level. The C2–C7 Cobb angle is now 18º degrees, the C3–C4 16º, C3–C5
fusion 3º, and C5–C6 also 3º.

evidence III) articles found. Although the follow-up times are
long in most studies, the poorly reported loss to follow-up in
some studies and the low rate of follow-up reported in oth-
ers leaves open the opportunity for substantial bias. Failure
to evaluate and control for potentially confounding factors
is another possible source of bias in these studies. The overall
strength of evidence regarding the extent to which coronal
malalignment may contribute to development of ASP is insuf-
ficient because no studies were identified.
Although the evidence is low, our results suggest that sag-
ittal malalignment may contribute to development of RASP.
No evidence was determined, however, for a role of coronal
alignment in either RASP or CASP.
Cervical spondylosis is the most common progressive
disease in the aging cervical spine.15 Adjacent-segment dis-
ease is a complication that has been described after surgical
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
intervention for cervical spondylosis. Hilibrand et al4 pub-
lished a series of 374 patients who demonstrated CASP with
an annual incidence of 2.9% per year and 25.6% at 10 years.
Recently, however, Wu et al16 reviewed 19,385 patients in a
nationwide database that had ACDF and determined a yearly
incidence of repeat ACDF surgery for CASP of 0.8%. At 10
years, 5.6% of the patients had undergone a second surgery
for CASP. These annual and cumulative incidences point to
the importance of reducing the risk of CASP development.
The cumulative incidence of RASP from 17% to 75% across
articles summarized in this systematic review underscores
the importance of considering alignment and methods for
decreasing the opportunity for malalignment. Unfortunately,
no article addressed any role of malalignment in the develop-
ment of ASP in patients with cervical disorders that have been
treated with posterior surgery.
www.spinejournal.com S81

BRS205230.indd S81 9/25/12 1:49 AM

 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023

Figure 4. (A) Initial T2-weighted magnetic resonance image (MRI) demonstrating the C5–C6 and C6–C7 spondylosis and sagittal alignment. There
is some evidence of degenerative disc disease in all the cervical discs. (B) Postoperative T2-weighted MRI after the initial 2-level ACDF with no
obvious adjacent segment disease at C4–C5. (C) T2-weighted MRI demonstrating the adjacent disc protrusion at C4–C5. (D) Immediate initial
postoperative lateral cervical spine radiograph. (E) Prerevision surgery cervical spine lateral radiograph demonstrating increase in kyphosis at
adjacent levels. (F) Postoperative lateral cervical spine radiography demonstrating the adjacent level construction, return of ventral disc height,
and adjacent level trend to lordosis.

Spinal segmental alignment and overall cervical alignment
were measured in different ways between the articles and
this may affect results (see Demographic and Results Table
in Supplemental Digital Material, Supplemental Digital Con-
tent 1, available at http://links.lww.com/BRS/A700). Faldini
et al10 determined spinal segmental alignment by measuring
the angle between a line drawn at the upper border of the ver-
tebral body proximal to the disc space involved and the line
parallel to the lower border of the body below. Overall align-
ment was measured by the same method of Katsuura et al,12
that is, by a line drawn parallel to the upper border of the
body of C2 and the line parallel to the lower border of C7,
the Cobb angle.17 To measure SSA, Katsuura et al12 used the
posterior tangential method,18,19 by lines drawn parallel to the
posterior vertebral bodies. SSA was determined by the angle
formed by the upper plane and the lower plane of the fused
segment. Kulkarni et al13 determined overall sagittal align-
ment by drawing a line between the posterior inferior edge of
C2 and the similar point on C7. If the intervening bodies were
anterior to this, then they were determined to be in lordosis,
on the line straight and behind the line kyphotic. The validity
of overall sagittal alignment measures has been investigated
before in radiographs. Both Harrison et al18 and Ohara et al20
agreed that either the Cobb method or the posterior tangen-
tial method are robust valid measures of overall sagittal align-
ment. The standard error of measurement, however, is slightly
S82 www.spinejournal.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
less in the posterior tangential method. Thus, the measure-
ments in the articles reviewed are reliable and not a source
of significant bias. In future studies, it would seem prudent
to use the tangential method, because it is slightly more accu-
rate. The caveat to this is that these methods have not been
compared in MRI and computed tomographic scans, where
measurements may be more accurate due to the resolution of
these imaging modalities.
The principle aim of surgery is to remove the pathology
causing neural compression, although the method of interven-
tion may differ. The amount of neural compression will be
least in the anatomical neutral position of the cervical spine.
The anatomical neutral position in the sagittal plane is one
of slight lordosis, although in cervical spondylosis, where
ventral disc height is reduced, the spine may trend toward
kyphosis.15 It would seem reasonable then that any surgical
intervention should attempt to address both the symptomatic
process and return the spine toward the normal. The logical
question is then: Does malalignment contribute to the devel-
opment of ASP?
The strength of evidence to evaluate this question is low
based primarily on methodological considerations. From
a clinical perspective, there are some additional aspects to
consider. Studies that provided sufficient data for some level
of analysis evaluated RASP and none evaluated CASP or
reported on the number of persons treated for symptomatic
October 2012

BRS205230.indd S82 9/25/12 1:49 AM

 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE
ASP. Matsumoto et al14 quantified the amount of adjacent
level pathology on a point scale system that used MRI to
evaluate the level of degeneration by looking for the amount
of disc protrusion, disc space narrowing, decrease in signal
intensity of the disc, and foraminal stenosis. Although the
grading system determined that more degeneration was seen
in those fused in a kyphotic angle greater than or equal to
5º, 1 parameter in their grading system (i.e., posterior disc
protrusion) showed a lower prevalence in those with kyphosis
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
(65% vs. 78%). In other words, those with a more lordotic
alignment demonstrated a higher prevalence of posterior disc
protrusions. This demonstrates the importance of address-
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023
ing clinically relevant ASP because radiological findings do
not necessarily manifest with clinically significant pathology.
The extent to which radiological degeneration at adjacent
segments might represent an intermediate (indirect) outcome
and is or is not linked to patient symptoms or function might
be a consideration in determining a potential downgrade for
Grades of Recommendation Assessment, Development, and
Evaluation.
Conceptually, it would be logical to attempt to restore
normal alignment in surgical procedures. As outlined in case
study 1, it is our practice to attempt to restore sagittal balance
to the extent possible with anterior surgery. By distracting the
ventral disc space, some lordosis can be restored due to the
anatomy of the cervical spine.15 Case study 2 presents a case
that demonstrates the complexity of the management of cervi-
cal spondylosis. Although segmental alignment was relatively
maintained at the fusion site, the global alignment was not
corrected. There was evidence of some degenerative changes
in the adjacent disc. The patient subsequently developed
ASP. This case shows that where global alignment cannot
be addressed, the patient should be carefully observed with
regard to the development of ASP where attention to adjacent
alignment was not optimum. The fusion actually reduced the
lordosis in the fused segment, thus apparently contributing to
the development of adjacent pathology. The revision surgery
attended to this and the patient has no evidence of adjacent
pathology in follow-up.
Future studies providing high-quality evidence on this par-
ticular topic may be challenging to design. However, high-
quality cohort analyses using multivariate statistical meth-
ods are required to verify any association between ASP and
postoperative malalignment. This is essential for minimizing
confounding variables in a condition with multifactorial etiol-
ogy. These confounding variables may include age, sex, smok-
ing history, preoperative alignment, or level of disease. Such
studies should clearly define criteria for determining RASP
and clear definitions for CASP. Evaluation of functional and
patient-reported outcomes and the extent to which they are or
are not associated with radiographical findings is also needed.
Studies to determine the most accurate and reliable measures
for cervical segmental and overall alignment are obviously
necessary, because there seem to be no studies in the literature
with regard to computed tomographic or MRI measurements.
Implications of global spine balance would also need to be
addressed; does the patient with lumbar sagittal imbalance
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205230.indd S83
Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
have a higher likelihood of developing CASP in the cervical
spine after an ACDF, for example?
CONCLUSION
Although the quality of available evidence is low, these studies
do suggest that sagittal deformity is a risk factor in the devel-
opment of ASP after reconstructive surgery for symptomatic
cervical spondylosis.
CONSENSUS STATEMENT
It is recommended that an attempt be made to maintain or
restore sagittal lordosis in surgical intervention for cervical
disorders.
Level of Evidence: Low
Strength of Statement: Weak
➢ Key Points
‰ There is low-level evidence that postsurgical sagittal
alignment increases the incidence of cervical RASP.
‰ There are no published studies investigating the role
of postsurgical coronal alignment in the development
of cervical ASP.
‰ The posterior tangential method seems to convey
the most accurate measure of sagittal alignment
in the cervical spine in radiographs, although other
methods such as the Cobb angle are accurate when
the spine is in lordosis.
‰ There are no published studies determining the
best method of cervical alignment measurement in
computed tomography or MRI.
Acknowledgments
The authors thank Ms. Nancy Holmes, RN, and Chi Lam,
MS, for their administrative assistance. The author M.G.F.
contributed to study concept, interpretation, manuscript prep-
aration, and manuscript revision; M.A.H. and H.J.K.: inter-
pretation, manuscript preparation, and manuscript revision;
A.C.S.: data analysis and interpretation, manuscript prepara-
tion, and manuscript revision; E.M.V.: data analysis, manu-
script preparation, and manuscript revision.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in
the HTML and PDF versions of this article on the journal’s
Web site (www. spinejournal.org).
References
1. Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy.
N Engl J Med 2005;353:392–9.
2. Fehlings MG, Arvin B. Surgical management of cervical degen-
erative disease: the evidence related to indications, impact, and
outcome. J Neurosurg Spine 2009;11:97–100.
3. Kepler CK, Hilibrand AS. Management of adjacent segment disease
after cervical spinal fusion. Orthop Clin North Am 2012;43:53–62, viii.
4. Hilibrand AS, Carlson GD, Palumbo MA, et al. Radiculopathy and
myelopathy at segments adjacent to the site of a previous anterior
cervical arthrodesis. J Bone Joint Surg Am 1999;81:519–28.
www.spinejournal.com S83
9/25/12 1:49 AM
 ADJACENT SEGMENT PATHOLOGY OF THE CERVICAL SPINE
5. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of
evidence to the journal. J Bone Joint Surg Am 2003;85-A:1–3.
6. Norvell DC, Dettori JR, Skelly AC, et al. Methodology for the sys-
tematic reviews on adjacent segment pathology. Spine 2012;37:
S10–7.
7. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and
strength of recommendations. BMJ 2004;328:1490.
8. West S, King V, Carey TS, et al. Systems to Rate the Strength of
Scientific Evidence. Evidence Report/Technology Assessment No.
47 (Prepared by the Research Triangle Institute-University of North
Carolina Evidence-based Practice Center, Contract No. 290–97-
0011): Agency for Healthcare Research and Quality. Rockville,
Downloaded from http://journals.lww.com/spinejournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
MD; 2002.
9. StataCorp. Stata Statistical Software: Release 9th ed. College
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/25/2023
Station, TX: StataCorp LP; 2005.
10. Faldini C, Pagkrati S, Leonetti D, et al. Sagittal segmental alignment
as predictor of adjacent-level degeneration after a Cloward proce-
dure. Clin Orthop Relat Res 2011;469:674–81.
11. Ishihara H, Kanamori M, Kawaguchi Y, et al. Adjacent segment
disease after anterior cervical interbody fusion. Spine J 2004;4:
624–8.
12. Katsuura A, Hukuda S, Saruhashi Y, et al. Kyphotic malalignment
after anterior cervical fusion is one of the factors promoting the
degenerative process in adjacent intervertebral levels. Eur Spine J
2001;10:320–4.
13. Kulkarni V, Rajshekhar V, Raghuram L. Accelerated spondylotic
changes adjacent to the fused segment following central cervical
S84 www.spinejournal.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205230.indd S84
Does Postsurgical Cervical Deformity Affect the
Risk of Cervical ASP? • Hansen et al
corpectomy: magnetic resonance imaging study evidence. J Neuro-
surg 2004;100(suppl Spine):2–6.
14. Matsumoto M, Okada E, Ichihara D, et al. Anterior cervical
decompression and fusion accelerates adjacent segment degenera-
tion: comparison with asymptomatic volunteers in a ten-year mag-
netic resonance imaging follow-up study. Spine (Phila Pa 1976)
2010;35:36–43.
15. Shedid D, Benzel EC. Cervical spondylosis anatomy: pathophysiol-
ogy and biomechanics. Neurosurgery 2007;60:S7–13.
16. Wu JC, Liu L, Wen-Cheng H, et al. The incidence of adjacent seg-
ment disease requiring surgery after anterior cervical diskectomy
and fusion: estimation using an 11-year comprehensive nationwide
database in Taiwan. Neurosurgery 2012;70:594–601.
17. Cobb JR. Outlines for the study of scoliosis. In:Edwards JW, ed.
Instructional Course Lecture. Ann Arbor, MI: American Academy
of Orthopaedic Surgeons; 1948:261–75.
18. Harrison DE, Harrison DD, Cailliet R, et al. Cobb method or
Harrison posterior tangent method: which to choose for lateral
cervical radiographic analysis. Spine (Phila Pa 1976) 2000;25:
2072–8.
19. Harrison DD. The Physics of Spinal Correction. Washington
DC: National Library of Medicine; publication number WE 725
H318C; 1986:319.
20. Ohara A, Miyamoto K, Naganawa T, et al. Reliabilities of and corre-
lations among five standard methods of assessing the sagittal align-
ment of the cervical spine. Spine (Phila Pa 1976) 2006;31:2585–91;
discussion 92.
October 2012
9/25/12 1:49 AM