CC BY-NC-ND 4.0 · Asian J Neurosurg 2023; 18(02): 293-300
DOI: 10.1055/s-0043-1768597
Original Article

Influence of Preoperative Sagittal Alignment on Functional Recovery in Operated Cases of Cervical Spondylotic Myelopathy

Shankar Acharya
1   Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
1   Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
Kashmiri Lal Kalra
1   Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
Rupinder Singh Chahal
1   Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
› Author Affiliations
Funding None.


Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated.

Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0–10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed.

Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11–50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; –11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery (p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant.

Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome.

Authors' Contribution

Shankar Acharya was responsible for mentoring, conceptualization, and supervision. He was also an operating surgeon. Varun Khanna was responsible for conceptualization, methodology, formal analysis, resources, data curation, and writing—original draft review and editing, the manuscript. He is also the corresponding author. Rupinder Chahal was responsible for the resources, analysis, and proofreading. He was also an operating surgeon. KL Kalra was responsible for data collection and proofreading, and also an operating surgeon.

Publication History

Article published online:
06 June 2023

© 2023. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient. Spine 2009; 34 (17) 1828-1833
  • 2 Kato M, Namikawa T, Matsumura A, Konishi S, Nakamura H. Effect of cervical sagittal balance on laminoplasty in patients with cervical myelopathy. Global Spine J 2017; 7 (02) 154-161
  • 3 Roguski M, Benzel EC, Curran JN. et al. Postoperative cervical sagittal imbalance negatively affects outcomes after surgery for cervical spondylotic myelopathy. Spine 2014; 39 (25) 2070-2077
  • 4 Tang JA, Scheer JK, Smith JS. et al; ISSG. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 2012; 71 (03) 662-669 , discussion 669
  • 5 Mohanty C, Massicotte EM, Fehlings MG, Shamji MF. Association of preoperative cervical spine alignment with spinal cord magnetic resonance imaging hyperintensity and myelopathy severity: analysis of a series of 124 cases. Spine 2015; 40 (01) 11-16
  • 6 Smith JS, Lafage V, Ryan DJ. et al. 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 2013; 38 (22, Suppl 1): S161-S170
  • 7 Ghogawala Z, Terrin N, Dunbar MR. et al. Effect of ventral vs dorsal spinal surgery on patient-reported physical functioning in patients with cervical spondylotic myelopathy: a randomized clinical trial. JAMA 2021; 325 (10) 942-951
  • 8 Fehlings MG, Santaguida C, Tetreault L. et al. Laminectomy and fusion versus laminoplasty for the treatment of degenerative cervical myelopathy: results from the AOSpine North America and International prospective multicenter studies. Spine J 2017; 17 (01) 102-108
  • 9 Wilson JRF, Badhiwala JH, Moghaddamjou A, Martin AR, Fehlings MG. Degenerative cervical myelopathy; a review of the latest advances and future directions in management. Neurospine 2019; 16 (03) 494-505
  • 10 Vedantam A, Rajshekhar V. Does the type of T2-weighted hyperintensity influence surgical outcome in patients with cervical spondylotic myelopathy? A review. Eur Spine J 2013; 22 (01) 96-106
  • 11 Gembruch O, Jabbarli R, Rashidi A. et al. Surgery for degenerative cervical myelopathy: what really counts?. Spine 2021; 46 (05) 294-299
  • 12 Tetreault L, Wilson JR, Kotter MRN. et al. Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy. Neurosurg Focus 2016; 40 (06) E14
  • 13 Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg 2000; 93 (2, Suppl): 199-204
  • 14 Revanappa KK, Rajshekhar V. Comparison of Nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy. Eur Spine J 2011; 20 (09) 1545-1551
  • 15 Buell TJ, Buchholz AL, Quinn JC, Shaffrey CI, Smith JS. Importance of sagittal alignment of the cervical spine in the management of degenerative cervical myelopathy. Neurosurg Clin N Am 2018; 29 (01) 69-82
  • 16 Shamji MF, Mohanty C, Massicotte EM, Fehlings MG. The association of cervical spine alignment with neurologic recovery in a prospective cohort of patients with surgical myelopathy: analysis of a series of 124 cases. World Neurosurg 2016; 86: 112-119
  • 17 Jain A, Rustagi T, Prasad G, Deore T, Bhojraj SY. Does segmental kyphosis affect surgical outcome after a posterior decompressive laminectomy in multisegmental cervical spondylotic myelopathy?. Asian Spine J 2017; 11 (01) 24-30
  • 18 Batzdorf U, Batzdorff A. Analysis of cervical spine curvature in patients with cervical spondylosis. Neurosurgery 1988; 22 (05) 827-836
  • 19 Hansen MA, Kim HJ, Van Alstyne EM, Skelly AC, Fehlings MG. Does postsurgical cervical deformity affect the risk of cervical adjacent segment pathology? A systematic review. Spine 2012; 37 (22, Suppl): S75-S84
  • 20 Koeppen D, Piepenbrock C, Kroppenstedt S, Čabraja M. The influence of sagittal profile alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A delta-omega-analysis. PLoS One 2017; 12 (04) e0174527
  • 21 Sielatycki JA, Armaghani S, Silverberg A, McGirt MJ, Devin CJ, O'Neill K. Is more lordosis associated with improved outcomes in cervical laminectomy and fusion when baseline alignment is lordotic?. Spine J 2016; 16 (08) 982-988
  • 22 Kurakawa T, Miyamoto H, Kaneyama S, Sumi M, Uno K. C5 nerve palsy after posterior reconstruction surgery: predictive risk factors of the incidence and critical range of correction for kyphosis. Eur Spine J 2016; 25 (07) 2060-2067