The gap between surgeon goal and achieved sagittal alignment in adult cervical spine deformity surgery
Authors: Smith Justin S. , Ben-Israel David , Kelly Michael P. , Lafage Virginie , Lafage Renaud , Klineberg Eric O. , Kim Han Jo , Line Breton , Protopsaltis Themistocles S. , Passias Peter , Eastlack Robert K. , Mundis Gregory M. , Riew K. Daniel , Kebaish Khaled , Park Paul , Gupta Munish C. , Gum Jeffrey L. , Daniels Alan H. , Diebo Bassel G. , Hostin Richard , Scheer Justin K. , Soroceanu Alex , Hamilton D. Kojo , Buell Thomas J. , Lewis Stephen J. , Lenke Lawrence G. , Mullin Jeffrey P. , Schwab Frank J. , Burton Douglas , Shaffrey Christopher I. , Ames Christopher P. , Bess Shay 
Published: January 2025

OBJECTIVE
Malalignment following cervical spine deformity (CSD) surgery can negatively impact outcomes and increase complications. Despite the growing ability to plan alignment, it remains unclear whether preoperative goals are achieved with surgery. The objective of this study was to assess how good surgeons are at achieving their preoperative goal alignment following CSD surgery.

METHODS
Adult patients with CSD were prospectively enrolled into a multicenter registry. Surgeons documented alignment goals prior to surgery, including C2–7 sagittal vertical axis (SVA), C2–7 sagittal Cobb angle, T1 slope minus cervical lordosis (TS-CL), and C7–S1 SVA. Goals were compared with achieved alignment, and the offsets (achieved goal) were calculated. General linear models were created for offset magnitude for each alignment parameter, controlling for baseline deformity and surgical factors.

RESULTS
The 88 enrolled patients had a mean age of 63.6 ± 13.0 years. The mean number of anterior and posterior instrumented levels was 3.5 ± 1.0 and 10.6 ± 4.5, respectively. Surgeons failed to achieve their preoperative alignment goals by an average of 17.2 (range 0.1–75.4) mm for C2–7 SVA, 10.3° (range 0.1°–45.5°) for C2–7 sagittal Cobb angle, 15.6° (range 0.0°–42.9°) for TS-CL, and 34.2 (range 0.3–113.7) mm for C7–S1 SVA. The sagittal alignment parameters with the highest rate of extreme outliers were TS-CL and C7–S1 SVA, with 32.2% exceeding 20° and 60.8% exceeding 20 mm from goal alignment, respectively. After controlling for baseline deformity and operative parameters, the only factor associated with achieving targeted alignment for C2–7 sagittal Cobb angle was greater baseline thoracic kyphosis (TK; B = −0.148, 95% CI −0.288 to −0.007, p = 0.040), and for TS-CL, the only associated factor was lower baseline TS-CL (B = 0.187, 95% CI 0.027–0.347, p = 0.022). Both lower TK and greater TS-CL may reflect increased baseline deformity through greater thoracic compensation and increased TS-CL mismatch, respectively. No significant associations were identified for C2–7 SVA and C7–S1 SVA.

CONCLUSIONS
Surgeons failed to achieve their preoperative alignment goals by an average of 17.2 mm for C2–7 SVA, 10.3° for C2–7 sagittal Cobb angle, 15.6° for TS-CL, and 34.2 mm for C7–S1 SVA. The few factors identified that were associated with offset between goal and achieved alignment suggest that achievement of goal alignment was most challenging for more severe deformities. Further advancements are needed to enable more consistent translation of preoperative alignment goals into the operating room for adult CSD correction.
Clinical trial registration no.: NCT01588054 (ClinicalTrials.gov).