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

Our aim was to define a treatment strategy for patients with severe cervical deformity (sCD).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.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.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.