Defining an Algorithm of Treatment for Severe Cervical Deformity Using Surgeon Survey and Treatment Patterns

Objective: Our aim was to define a treatment strategy for patients with severe cervical deformity (sCD). Methods: Surgical patients with sCD were isolated based on preoperative radiographic parameters. We sent 10 sCD cases to 7 surgeons to find consensus on approach, upper instrumented vertebrae (UIVs), lower instrumented vertebrae (LIVs), and osteotomy. We performed a descriptive analysis and created a treatment algorithm from the survey and then analyzed a database of surgical patients to find the frequency of following our algorithm. Results: We found consensus on 7 cases for a posterior approach because of cervicothoracic deformity. Of 15 patients within our sCD database that had cervicothoracic deformity, 13 had a posterior approach. There was consensus on 2 cases for an anteroposterior approach because of local kyphosis. Of 25 patients that had local kyphosis, 18 had an anterior approach. In 4 cases, there was consensus of UIV of C2. Of 35 cases that had posterior fusion more than 6 levels, 20 had UIV of C2. In 3 cases, there was consensus of LIV below a previously fused spine. Of 36 patients that had a fusion of T6 or higher, 34 had LIV below the previous UIV. In 6 cases, there was consensus against an osteotomy because of cervical spine flexibility. Nine of 12 patients that had an osteotomy in our database had no flexibility on dynamic radiographs. Conclusions: We outline an algorithm for deciding approach, UIV, LIV, and whether to do an osteotomy for patients with sCD based on consensus recommendations among spine surgeons.