Cervical spinal deformity (CSD) is a complex condition characterized by abnormal curvature and cervical spine alignment. It can lead to a multitude of symptoms, including chronic pain, neurological deficits, and functional impairments, severely impacting an individual’s health-related quality of life (HRQoL). Surgical intervention is often necessary to address the deformity and alleviate symptoms, but optimal surgical strategies remain a topic of ongoing research and debate. This narrative review aims to provide an in-depth overview of the surgical management of CSD, focusing on optimizing patient outcomes and enhancing readers’ understanding of the complexities involved. We begin by discussing the importance of preoperative assessment, including comprehensive radiographic evaluation and careful consideration of the global spinal alignment. The relationship between the cervical spine and the reciprocal changes that occur are explored to guide surgeons in their decision-making process. Furthermore, we delve into the selection of fusion levels, emphasizing the significance of identifying the primary driver of deformity. We review the current literature on optimal alignment targets and strategies to optimize surgical planning. By providing a comprehensive analysis of the surgical management of CSD, this review aims to enhance the readers’ knowledge and assist surgeons in making informed decisions when planning and executing surgical interventions. Understanding the intricacies of CSD correction and the latest advancements in the field can ultimately improve patient outcomes and enhance HRQoL for individuals suffering from this challenging condition.
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A systematic review and meta-analysis of sagittal cervical spine parameters: Normative values, correlation with quality of life, and biomechanical modeling Vinicius Ricieri Ferraz, Carlos R. Goulart, Tobias Alecio Mattei North American Spine Society Journal (NASSJ).2026; 25: 100819. CrossRef
Lordosis Distribution Index in an Asymptomatic Elderly Population : The Role of Lower and Upper Lumbar Lordosis According to Individual Pelvic Incidence and Roussouly Type Seung-Jae Hyun, Sanghyun Han, Youngbae B. Kim Journal of Korean Neurosurgical Society.2026; 69(1): 92. CrossRef
Impact of T1 Slope as a Predictor of Loss of Cervical Lordosis and Health-Related Quality of Life after Laminoplasty in Patients with Ossification of the Posterior Longitudinal Ligament : A Retrospective Cohort Study Ji-Ho Jung, Jong-Hoon Jeong, Jong-Hwan Hong, Moon-Soo Han, Jung-Kil Lee Journal of Korean Neurosurgical Society.2026; 69(1): 124. CrossRef
C2 Slope as an Independent Predictor of Cervical Lordosis Loss Following Laminoplasty Bin Zheng, Panfeng Yu, Zhenqi Zhu, Yan Liang, Haiying Liu Orthopaedic Surgery.2026; 18(3): 569. CrossRef
Does Higher T1 Slope Predict Poor Outcomes Following Posterior Cervical Fusion for Degenerative Pathology? Harsh Jain, Sameer Sundrani, Iyan Younus, Nick De Oliveira, Omar Zakieh, Maryam Jawid, Naadir Jamal, Hani Chanbour, Tyler Zeoli, Ranbir Ahluwalia, Mitchell Bowers, Raymond J. Gardocki, Amir M. Abtahi, Byron F. Stephens, Scott L. Zuckerman World Neurosurgery.2026; 209: 124920. CrossRef
Sagittal balance of the cervical spine in adults: a non-systematic literature review R. S. Chernyshyov, V. B. Lebedev, B. R. Kinzyagulov, A. A. Zuev Russian Journal of Spine Surgery (Khirurgiya Pozvonochnika).2026; 23(1): 92. CrossRef
Factors influencing patient satisfaction in adult thoracolumbar deformity surgery: a single-center retrospective study Joo-Sung Kim, Dong-Kyu Kim, Hyun-Jun Jang, Bong-Ju Moon, Jeong-Yoon Park, Kyung-Hyun Kim Neurofunction.2026; 22(2): 33. CrossRef
Investigation of spinopelvic sagittal alignment and its correlations in asymptomatic pediatric populations Hao Qi, ZengHui Zhao, Feiyu Zu, Chenchen Wang, Chenxi Wang, Zuzhuo Zhang, Jianhua Ren, Rui Xue, Zhaoxuan Wang, Zhiyong Hou, Wei Chen, Di Zhang Scientific Reports.2025;[Epub] CrossRef
Cervical Sagittal Alignment Revisited on the Path to Personalized Spine Surgery: A Big Picture Perspective Through Bibliometric Analysis and Visualization Luke L. Jouppi, Clifford Pierre, Anna Gorbacheva, Julius Gerstmeyer, Colin Gold, Cameron Hogsett, Nicholas Minissale, Mark Kraemer, Stephen Lockey, Amir Abdul-Jabbar, Rod J. Oskouian, Jens R. Chapman World Neurosurgery.2025; 202: 124387. CrossRef
Objective C2 slope (C2S), a cervical parameter mathematically approximated as T1 slope minus cervical lordosis (T1S–CL), predicts functional improvement in cervical deformity patients. Nonetheless, C2S is a positional parameter based only on the horizontal axis. The current study aims to introduce novel odontoid parameters and establish their relationships with patient-reported health-related quality of life (HRQoL).
Methods Lateral plain radiographs of 32 adults who underwent multilevel posterior cervical fusion were analyzed. The odontoid parameters included odontoid incidence (OI), C2S, odontoid tilt (OT), and gravity line-C2 distance (GL-C2), while the cervical parameters were the Cobb angle at C0–1, C1–2, C0–2, C2–7, C2–7 sagittal vertical axis (cSVA), T1 slope, and T1S–CL. The range of motion (ROM) of the occipito-atlantoaxial complex was measured in flexion and extension plain radiographs. Scores on the Neck Disability Index (NDI) and visual analogue scale (VAS) for axial neck (VASn) and arm pain were measured.
Results Compared to asymptomatic subjects, patients had larger C2S, cSVA, and T1S–CL, and smaller OT. Preoperatively, OI was significantly correlated with the ROM of C1–2 (r = 0.37, p < 0.05) and C0–2 (r = 0.46, p < 0.01). OT and C2S had significant correlations with the C0–1, C1–2, and C0–2 angles, GL-C2, and T1S–CL. Postoperative NDI scores were significantly correlated with OI (r = -0.40, p < 0.05) and OT (ρ = -0.37, p < 0.05). VASn was significantly correlated with GL-C2 (r = -0.35, p < 0.05).
Conclusion The odontoid parameters were significantly correlated with established cervical parameters and HRQoL measures. OI is a constant parameter representing the individual's compensatory reservoir at the upper cervical spine.
The effect of cervical spine flexion-extension motion on odontoid parameters Longao Huang, Dun Liu, Hongyuan Xu, Junfei Feng, Tao Kang, Shengwang Wei, Hua Jiang Journal of Orthopaedic Surgery and Research.2025;[Epub] CrossRef
Correlation analysis between preoperative odontoid incidence and clinical outcomes 2 years after anterior cervical discectomy and fusion Yan Gong, Hao Liu, Yanchi Gan, Jiahui He, Zelin Zhou, Hang Zhuo, Yu Liu, De Liang, Hui Ren, Xiaobing Jiang, Zhaojun Cheng Journal of Orthopaedic Surgery and Research.2025;[Epub] CrossRef
Lower C2 slope and milder uncovertebral joint degeneration are risk factors for pseudarthrosis after single-level anterior cervical corpectomy and fusion (ACCF): retrospective study of 102 patients with minimum 2-year follow-up Haoxiang Wang, Tian Xia, Ruomu Qu, Hanbo Geng, Yu Sun, Fengshan Zhang, Shengfa Pan, Xin Chen, Yanbin Zhao, Feifei Zhou Journal of Orthopaedic Surgery and Research.2025;[Epub] CrossRef
Impact of anterior controllable antedisplacement and fusion (ACAF) on cervical lordosis and sagittal alignment in OPLL: A comparative radiographic analysis Shunmin Wang, Dong Liu, Jincui Li, Jingchuan Sun, Tiefeng Li, Jiangang Shi Journal of Orthopaedics.2025; 70: 158. CrossRef
Odontoid parameters in subjects with and without degenerative cervical spondylosis Tao Kang, Weiyou Chen, Longao Huang, Hongyuan Xu, Hua Jiang BMC Musculoskeletal Disorders.2025;[Epub] CrossRef
Introducing the Modified Cobb Angle for Measuring Cervical Spine Curvature During Swallowing Catriona M. Steele, Makaya O' Grady, Sima Farpour, Melanie Peladeau‐Pigeon, Sophia Werden Abrams, Maureen Folsom, Emily K. Plowman, Ashwini M. Namasivayam‐MacDonald Laryngoscope Investigative Otolaryngology.2025;[Epub] CrossRef
The Significance of Odontoid Incidence in Patients With Cervical Spondylotic Myelopathy Hongyu Qin, Weiyou Chen, Longao Huang, Xin Xiao, Qinghua Yang, Hua Jiang Global Spine Journal.2024; 14(8): 2374. CrossRef
Variation of Odontoid Incidence According to Age in Asymptomatic Children Yuwang Du, Weiyou Chen, Hongyuan Xu, Xiao Liang, Chongyang Wang, Hongyu Qin, Hua Jiang World Neurosurgery.2024; 190: e496. CrossRef
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Optimizing Surgical Strategy for Cervical Spinal Deformity: Global Alignment and Surgical Targets Jae-Koo Lee, Seung-Jae Hyun, Ki-Jeong Kim Neurospine.2023; 20(4): 1246. CrossRef
Commentary on “Clinical Impact and Correlations of Odontoid Parameters Following Multilevel Posterior Cervical Fusion Surgery” Sang Hun Lee Neurospine.2022; 19(4): 921. CrossRef
Significance of Atlantoaxial and Subaxial Spinal Instability in Cervical Spinal Spondylosis: Commentary on “Clinical Impact and Correlations of Odontoid Parameters Following Multilevel Posterior Cervical Fusion Surgery” Atul Goel Neurospine.2022; 19(4): 924. CrossRef
Objective Adult spinal deformity (ASD) have lower health-related quality of life (HRQoL) compared to the general population. Applying Rasch measurement theory (RMT), this study tested the revised Scoliosis Research Society-22 (SRS-22r) HRQoL instrument among symptomatic adult patients with degenerative spinal disorders and varying degrees of ASD.
Methods SRS-22r data from 637 outpatient spine clinic patients with degenerative spine conditions were investigated for unidimensionality, item/scale fit, differential item functioning (DIF), scale coverage/targeting, and person separation index (PSI) using RMT.
Results Unidimensionality of the SRS-22r was not supported for either the total score or for 3 of its 5 domains. Item fit was acceptable for 11/22 items. The individual domains showed good coverage despite the degree of structural disorders. Ordered thresholds were achieved by merging response categories in some of the items. DIF towards age or sex was found in 11/22 items and in some domain items. The PSI exceeded 0.7 for the SRS-22r total score.
Conclusion The individual domain scores of the SRS-22r perform better than the total score providing good coverage and targeting among patients with ASD. Refinements of items and domains may improve the structural validity of the instrument to meet the criteria for measuring ASD patients, even when multidimensionality persists.
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Neurospine 2021;18(3):608-617. Published online September 30, 2021
Objective This study aimed to identify the sagittal parameters associated with health-related quality of life and genetic variations that increase the risk of adult spinal deformity (ASD) onset in the older population.
Methods We recruited 120 participants who had a sagittal vertical axis > 50 mm in a sagittal imbalance study. Sagittal radiographic parameters, cross-sectional area, and intramuscular fatty infiltration using the Goutallier classification in the paraspinal lumbar muscles were evaluated. Functional scales included the self-reported Oswestry Disability Index (ODI), 36-item Short Form Health Survey (SF-36), and visual analogue scales (VAS) for back and leg pain. We performed whole-exome sequencing and an exome-wide association study using the 100 control subjects and 63 individuals with severe phenotypes of sagittal imbalance.
Results Pelvic incidence minus lumbar lordosis (PI–LL) mismatch was negatively associated with the SF-36 and positively correlated with ODI and VAS for back and leg pain. PI–LL was related to the quality and size of the paraspinal muscles, especially the multifidus muscle. We identified common individual variants that reached exome-wide significance using single-variant analysis. The most significant single-nucleotide polymorphism was rs78773460, situated in an exon of the SVIL gene (odds ratio, 9.61; p = 1.15 × 10-9).
Conclusion Older age, higher body mass index, and a more significant PI–LL mismatch were associated with unfavorable results on functional scales. We found a genetic variation in the SVIL gene, which has been associated with the integrity of the cytoskeleton and the development of skeletal muscles, in severe ASD phenotypes. Our results help to elucidate the pathogenesis of ASD.
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Objective The purpose of the present study was to evaluate the natural course of primary degenerative sagittal imbalance (PDSI), its aggravating factors, and health-related quality of life (HRQoL) associated with various spinal alignment parameters (SAPs) in patients with PDSI who have not undergone surgery.
Methods One hundred three participants volunteered to participate. The SAPs, including T1 pelvic angle (T1PA), thoracolumbar tilt, and thoracolumbar slope (TLS), were measured on whole-spine standing radiographs. The back and lumbar muscle volumes were measured. To determine HRQoL at baseline and at 2-year follow-up, face-to-face questionnaires were administered, which included visual analogue scale of the back and leg, physical component summary/mental component summary of 36-item Short Form Health Survey, Oswestry Disability Index (ODI), and Mini-Mental State Examination.
Results Overall HRQoL measures had improved after 2 years of follow-up compared to baseline. PDSI aggravation was observed in 18 participants (26.1%). TLS, sagittal vertical axis (SVA), and T1PA were strongly correlated with each other. TLS, SVA, and T1PA were correlated with ODI score. Among them, TLS was most highly correlated with ODI score. TLS greater than -3.5° was a predicting factor for PDSI aggravation (p = 0.034; 95% confidence interval, 1.173–63.61; odds ratio, 8.636).
Conclusion The present study implied that PDSI does not necessarily worsen with aging. TLS is an appropriate parameter for assessing the clinical situation in patients with PDSI. Furthermore, a TLS greater than -3.5° predicts PDSI aggravation; thus, TLS may be a useful parameter for predicting prognosis in PDSI.
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Objective Extension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.
Methods ASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.
Results A total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.
Conclusion A UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.
When spinal imbalance occurs, the human body reacts through various compensatory mechanisms to maintain the head over the pelvis and to retain a horizontal gaze. These compensations occur through mobile spine segments as well as pelvic tilt and lower extremities. The purpose of this review was to understand the surgical impact on global sagittal alignment and health-related quality of life (HRQoL) following cervical kyphosis correction surgery. The cervical kyphosis correction surgery induces reciprocal changes in craniocervical and thoracolumbar alignment. Successful cervical deformity correction needs to focus not only on restoring proper cervical lordosis, but also on achieving global balance of the cervical spine with other parts of the spine. The goal of the surgery is to achieve occiputtrunk (OT) concordance (the center of gravity-C7 sagittal vertical axis < 30 mm) and cervical sagittal balance. Once OT-concordance is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize global spinal alignment. Reciprocal changes after surgery exhibit different patterns depending on whether patients have compensation ability in their thoracolumbar spine or not. C2–7 sagittal vertical axis and sagittal morphotype of the cervical kyphosis are correlated with HRQoL. Changes in cervical lordosis minus T1 slope correlate to HRQoL improvements.
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Objective To investigate the utility of full-endoscopic lumbar discectomy (FELD) in surgical treatment of recurrent lumbar disc herniation (RLDH).
Methods Forty-five patients were prospectively studied. All patients were subjected to FELD for RLDH. They were assessed preoperatively and in regular intervals at 6 weeks and 3 months, 6 months, and 12 months postoperatively. Evaluation was conducted with visual analogue scale for leg (VAS-LP) and low back (VAS-BP) pain. Short-Form 36 Health Survey Questionnaire was utilized for health-related quality of life assessment.
Results All studied parameters featured statistically significant amelioration at all follow-up intervals. Maximal improvement was in general at 6 weeks observed, with subsequent lesser improvement until 6 months and stabilization until the end of follow-up. Comparative assessment indicated that VAS-BP displayed quantitatively lower improvement, whereas physical function, bodily pain, and role-emotional parameters demonstrated greater amelioration.
Conclusion FELD is associated with a favorable impact in postoperative daily life of patients with RLDH.
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