Impact of the Inclusion of C2 in Posterior Cervical Fusions for Cervical Myelopathy on Sagittal Cervical Alignment

Study Design: Retrospective cohort study. Objective: To determine the impact of including C2 in posterior fusions on radiographic parameters of cervical alignment in cervical spondylotic myelopathy. Summary of Background Data: Despite the use of posterior instrumentation and arthrodesis after cervical laminectomy, loss of lordosis and the development of kyphosis are prevalent. Inadequate cervical lordosis and other measures of sagittal cervical alignment have been shown to correlate with disability, general health scores, and severity of myelopathy. The role of C2 in the posterior tension band, which maintains sagittal alignment, differs from the subaxial spine, as it is the insertion point for erector spinae muscles that play a critical role in maintaining posture. Patients and Methods: This study compares the radiographic outcomes of sagittal balance between 2 cohorts of patients who underwent posterior cervical decompression and fusion for cervical myelopathy over a 12-year period at a single institution. Demographic and surgical characteristics were collected using the electronic medical record of patients undergoing posterior cervical fusions (PCF) which included the axis [axial fusion (AF)] and those that were subaxial fusions (SAF). Radiographic measurements included preopertaive and postoperative C2-C7 lordosis (CL), C2-C7 sagittal vertical axis (SVA), and T1 slope (T1S). Results: After review of the electronic medical records, 229 patients were identified as having PCF and decompression for treatment of myelopathy. One hundred sixty-seven patients had AF, whereas 62 had SAF. PCF resulted in loss of CL in both cohorts. Although there was no statistical difference in postoperative CL, there was a significant increase in SVA (P<0.001) and T1S (P<0.001) with AF. Conclusions: PCF often result in loss of lordosis. When compared with SAF, inclusion of C2 into the fusion construct may result in worsened sagittal balance, increasing the SVA and T1S.