Anterior cervical discectomy and fusion can restore cervical sagittal alignment in degenerative cervical disease

  • Han Jo Kim
  • Byung-Wan ChoiEmail author
  • JeaSeok Park
  • Sebastien Pesenti
  • Virginie Lafage
Original Article • SPINE - CERVICAL



The purpose of this study was to evaluate its effect on the restoration and maintenance of cervical sagittal alignment in usual cervical degenerative diseases without preoperative sagittal malalignment.

Materials and methods

We retrospectively evaluated 108 patients who were diagnosed with degenerative cervical disease and underwent ACDF (allograft and plating) with > 1-year follow-up. For radiographic evaluation, we analysed segmental and C2–7 cervical lordosis, disc height, C2–7 sagittal vertical axis (SVA), T1 slope, and T1 slope minus C2–7 lordosis (T1S − CL) in lateral X-ray. Clinical assessment was based on arm VAS, neck VAS, and NDI scores. Correlation analysis was performed across the pre–post-changes in radiological parameters. Correlations between the changes in radiological and clinical parameters at final follow-up were also analysed.


C2–7 lordosis was 7.13° preoperatively and increased to 13.06° (p < 0.001) and maintained at 10.08° at final follow-up (p = 0.007). Segmental lordosis increased from 0.66° to 8.33° and maintained at 5.19° (p < 0.001). Segmental disc height was 4.67 mm preoperatively (increased to 7.13 mm postoperatively and decreased to 5.74 mm at final follow-up) (p < 0.001). SVA distance (31.53 mm to 30.02 mm) (p = 0.750) and T1 slope (30.03° to 31.37°) did not show meaningful change after surgery. Increase in segmental lordosis was correlated to an increase in C2–7 lordosis (p < 0.001). C2–7 SVA change correlated with both the T1 slope change (p < 0.001) and T1S − CL (p = 0.012). Change in SVA was correlated to a change in segmental lordosis and T1 slope (p = 0.003, p = 0.014). Clinical outcomes did not correlate with radiological findings.


ACDF for the treatment of degenerative cervical disease without preoperative deformity was effective in restoring cervical sagittal alignment. Improvement of segmental lordosis related to an improvement in C2–7 lordosis and SVA. Radiological sagittal alignment did not show any relation with clinical outcomes in usual degenerative cases.


Cervical Sagittal alignment Anterior discectomy and fusion C2–7 lordosis C2–7 SVA 


Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The present study was approved by our institutional review board.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, Patel AA, Traynelis VC, Kim HJ, Shaffrey CI, Smith JS, Lafage V (2013) Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976) 38:S149–S160CrossRefGoogle Scholar
  2. 2.
    Scheer JK, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B et al (2013) Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 19:141–159CrossRefPubMedGoogle Scholar
  3. 3.
    Scheer JK, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B, Bess S, Shaffrey CI, Deviren V, Lafage V, Schwab F, Ames CP, International Spine Study Group (2013) Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 19:141–159CrossRefPubMedGoogle Scholar
  4. 4.
    Park MS, Kelly MP, Lee DH, Min WK, Rahman RK, Riew KD (2014) Sagittal alignment as a predictor of clinical adjacent segment pathology requiring surgery after anterior cervical arthrodesis. Spine J 14:1228–1234CrossRefPubMedGoogle Scholar
  5. 5.
    Smith GW, Robinson RA (1958) The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 40:607–624CrossRefPubMedGoogle Scholar
  6. 6.
    Shriver MF, Lewis DJ, Kshettry VR, Rosenbaum BP, Benzel EC, Mroz TE (2015) Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis. Spine J 15:2016–2027CrossRefPubMedGoogle Scholar
  7. 7.
    Quinn JC, Kiely PD, Lebl DR, Hughes AP (2015) Anterior surgical treatment of cervical spondylotic myelopathy: review article. HSS J 11:15–25CrossRefPubMedGoogle Scholar
  8. 8.
    Kim SY, Park KS, Jung SS, Chung SY, Kim SM, Park MS, Kim HK (2012) An early comparative analysis of the use of autograft versus allograft in anterior cervical discectomy and fusion. Korean J Spine 9:142–146CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Smith JS, Lafage V, Ryan DJ, Shaffrey CI, Schwab FJ, Patel AA, Brodke DS, Arnold PM, Riew KD, Traynelis VC, Radcliff K, Vaccaro AR, Fehlings MG, Ames CP (2013) Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy study. Spine (Phila Pa 1976) 38:S161–S170CrossRefGoogle Scholar
  10. 10.
    Kwon WK, Kim PS, Ahn SY, Song JY, Kim JH, Park YK, Kwon TH, Moon HJ (2017) Analysis of associating factors with C2-7 sagittal vertical axis after two-level anterior cervical fusion: comparison between plate augmentation and stand-alone cages. Spine (Phila Pa 1976) 42:318–325CrossRefGoogle Scholar
  11. 11.
    Lee CH, Hyun SJ, Kim MJ, Yeom JS, Kim WH, Kim KJ, Jahng TA, Kim HJ, Yoon SH (2013) Comparative analysis of 3 different construct systems for single-level anterior cervical discectomy and fusion: stand-alone cage, iliac graft plus plate augmentation, and cage plus plating. J Spinal Disord Tech 26:112–118CrossRefPubMedGoogle Scholar
  12. 12.
    Song KJ, Taghavi CE, Lee KB, Song JH, Eun JP (2009) The efficacy of plate construct augmentation versus cage alone in anterior cervical fusion. Spine (Phila Pa 1976) 34:2886–2892CrossRefGoogle Scholar
  13. 13.
    Kawakami M, Tamaki T, Yoshida M, Hayashi N, Ando M, Yamada H (1999) Axial symptoms and cervical alignments after cervical anterior spinal fusion for patients with cervical myelopathy. J Spinal Disord 12:50–56CrossRefPubMedGoogle Scholar
  14. 14.
    Tang JA, Scheer JK, Smith JS et al (2015) The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 76:S14–S21 (discussion S21) CrossRefPubMedGoogle Scholar
  15. 15.
    Protopsaltis TS, Scheer JK, Terran JS et al (2015) How the neck affects the back: changes in regional cervical sagittal alignment correlate to HRQOL improvement in adult thoracolumbar deformity patients at 2-year follow-up. J Nuerosurg Spine 23(2):153–158CrossRefGoogle Scholar
  16. 16.
    Oe S, Togawa D, Nakai K et al (2015) The influence of age and sex on cervical spinal alignment among volunteers aged over 50. Spine (Phila Pa 1976) 40:1487–1494CrossRefGoogle Scholar
  17. 17.
    Sakai K, Yoshii T, Hirai T, Arai Y, Shinomiya K, Okawa A (2017) Impact of the surgical treatment for degenerative cervical myelopathy on the preoperative cervical sagittal balance: a review of prospective comparative cohort between anterior decompression with fusion and laminoplasty. Eur Spine J 26:104–112CrossRefPubMedGoogle Scholar
  18. 18.
    Patwardhan AG, Havey RM, Khayatzadeh S, Muriuki MG, Voronov LI, Carandang G, Nguyen NL, Ghanayem AJ, Schuit D, Patel AA, Smith ZA, Sears W (2015) Postural consequences of cervical sagittal imbalance: a novel laboratory model. Spine (Phila Pa 1976) 40:783–792CrossRefGoogle Scholar
  19. 19.
    Kim JH, Park JY, Yi S et al (2015) Anterior cervical discectomy and fusion alters whole-spine sagittal alignment. Yonsei Med J 56:1060–1070CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Gillis CC, Kaszuba MC, Traynelis VC (2016) Cervical radiographic parameters in 1- and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine 25:421–429CrossRefPubMedGoogle Scholar
  21. 21.
    Hyun SJ, Kim KJ, Jahng TA, Kim HJ (2016) Relationship between T1 slope and cervical alignment following multi-level posterior cervical fusion surgery: impact of T1 slope minus cervical lordosis. Spine (Phila Pa 1976) 41:E396–E402CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  • Han Jo Kim
    • 1
  • Byung-Wan Choi
    • 2
    Email author
  • JeaSeok Park
    • 2
  • Sebastien Pesenti
    • 1
  • Virginie Lafage
    • 1
  1. 1.Department of Orthopedic SurgeryHospital for Special SurgeryNew YorkUSA
  2. 2.Department of Orthopedic SurgeryInje University, Haeundae Paik HospitalBusanRepublic of Korea

Personalised recommendations