CLINICAL ARTICLE

J Neurosurg Spine 36:93–98, 2022

Association of findings on preoperative extension lateral

cervical radiography with osteotomy type, approach, and
postoperative cervical alignment after cervical deformity
surgery
Hai V. Le, MD,1 Joseph B. Wick, MD,1 Renaud Lafage, MS,2 Gregory M. Mundis Jr., MD,3
Robert K. Eastlack, MD,3 Shay Bess, MD,4 Douglas C. Burton, MD,5 Christopher P. Ames, MD,6
Justin S. Smith, MD, PhD,7 Peter G. Passias, MD,8 Munish C. Gupta, MD,9 Virginie Lafage, PhD,2
Eric O. Klineberg, MD,1 and the International Spine Study Group
1
Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California; 2Hospital for Special Surgery, New York,
New York; 3Department of Orthopedics, Scripps Clinic, La Jolla, California; 4Denver International Spine Center, Presbyterian
St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado; 5Department of Orthopaedic Surgery, University of Kansas
School of Medicine, Kansas City, Kansas; 6Department of Neurosurgery, University of California, San Francisco, California;
7
Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; 8Department of Orthopedic
Surgery, NYU Langone Health, New York, New York; and 9Department of Orthopaedic Surgery, Washington University School of
Medicine, St. Louis, Missouri

OBJECTIVE The authors’ objective was to determine whether preoperative lateral extension cervical spine radiography
can be used to predict osteotomy type and postoperative alignment parameters after cervical spine deformity surgery.
METHODS A total of 106 patients with cervical spine deformity were reviewed. Radiographic parameters on preopera-
tive cervical neutral and extension lateral radiography were compared with 3-month postoperative radiographic align-
ment parameters. The parameters included T1 slope, C2 slope, C2–7 cervical lordosis, cervical sagittal vertical axis, and
T1 slope minus cervical lordosis. Associations of radiographic parameters with osteotomy type and surgical approach
were also assessed.
RESULTS On extension lateral radiography, patients who underwent lower grade osteotomy had significantly lower T1
slope, T1 slope minus cervical lordosis, cervical sagittal vertical axis, and C2 slope. Patients who achieved more normal
parameters on extension lateral radiography were more likely to undergo surgery via an anterior approach. Although
baseline parameters were significantly different between neutral lateral and extension lateral radiographs, 3-month
postoperative lateral and preoperative extension lateral radiographs were statistically similar for T1 slope minus cervical
lordosis and C2 slope.
CONCLUSIONS Radiographic parameters on preoperative extension lateral radiography were significantly associated
with surgical approach and osteotomy grade and were similar to those on 3-month postoperative lateral radiography.
These results demonstrated that extension lateral radiography is useful for preoperative planning and predicting postop-
erative alignment.
https://thejns.org/doi/abs/10.3171/2021.3.SPINE202156
KEYWORDS cervical deformity; radiograph; approach; osteotomy; lordosis; sagittal vertical axis; slope

A
patients with cervical spine deformity (CSD)
dult cal challenges to surgeons and high risks of perioperative
can present with intractable neck pain, disability, complications for patients.4,5 Thus, careful patient selec-
and neurological dysfunction.1–3 Surgical inter- tion, precise surgical planning, and meticulous execution
vention may be necessary when nonoperative manage- are critical to achieving optimal alignment correction
ment has failed. CSD correction poses significant techni- while minimizing risks of serious injuries.2,3

ABBREVIATIONS C2S = C2 slope; CL = cervical lordosis; CSD = cervical spine deformity; cSVA = C2–7 sagittal vertical axis; ELXR = extension lateral radiography; T1S =
T1 slope; T1S-CL = T1S minus CL.
SUBMITTED December 30, 2020. ACCEPTED March 10, 2021.
INCLUDE WHEN CITING Published online September 3, 2021; DOI: 10.3171/2021.3.SPINE202156.

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Le et al.

TABLE 1. Description of cervical osteotomy nomenclature, as first described by Ames et al.7

Osteotomy
Grade Resection Description Surgical Approach
1 Partial facet joint resection Anterior cervical discectomy, including partial uncovertebral joint resec- A, P, AP, PA, APA, PAP
tion, posterior facet capsule resection, or partial facet resection
2 Complete facet joint/Ponte osteotomy Both superior & inferior facets at a given segment are resected; other P, AP, PA, APA, PAP
posterior elements of vertebra, including lamina & spinous processes,
may also be resected
3 Partial or complete corpectomy Partial or complete corpectomy, including discs above & below A, AP, PA, APA, PAP
4 Complete uncovertebral joint resec- Anterior osteotomy through lat body & uncovertebral joints & into trans- A, PA, AP, APA, PAP
tion to transverse foramen verse foramen
5 Opening wedge osteotomy Complete posterior element resection w/ osteoclastic fracture & open P, PA, AP, APA, PAP
wedge creation
6 Closing wedge osteotomy Complete posterior element resection & pedicle resection w/ closing P, PA, AP, APA, PAP
wedge creation
7 Complete vertebral column resection Resection of 1 or more entire vertebral body & disc, including complete AP, PA, APA, PAP
uncovertebral joint & posterior lamina & facets
A = anterior; AP = anterior-posterior; APA = anterior-posterior-anterior; P = posterior; PA = posterior-anterior; PAP = posterior-anterior-posterior.

CSD surgery can be performed with anterior, poste- surgery were included. CSD was defined as any of the
rior, or combined approaches.2,3,6 Approach selection is following: cervical kyphosis (C2–7 sagittal Cobb angle >
complex and influenced by various patient- and surgeon- 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7
specific factors. Furthermore, the type of osteotomy cho- sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical
sen to achieve the best possible deformity correction var- angle > 25°. Patients were excluded if they did not undergo
ies greatly among surgeons because no definite surgical neutral lateral radiography and ELXR, or if their deformi-
algorithm exists.7 Consequently, a major focus in CSD ty was not limited to the cervical or cervicothoracic spine.
research over the past decade has been to better under- Demographic data, including sex and age, and surgi-
stand radiographic parameters and their utility in surgi- cal data, including primary versus revision cervical sur-
cal planning and prediction of clinical and radiographic gery, grade of osteotomy based on the Ames classification
outcomes.8–11 (Table 1),7 and surgical approach, were collected. Cervical
Assessing deformity flexibility is critical in preopera- alignment parameters were measured on lateral plain ra-
tive planning for CSD correction. Dynamic radiography diography and analyzed using a dedicated and validated
with full-neck flexion and extension can provide invalu- software system (SpineView, ENSAM Laboratory of Bio-
able information,2,3 but no clear radiographic guidelines mechanics).12 Parameters of interest included T1 slope
exist for its use in preoperative planning. For example, it is (T1S) (angle between the T1 superior endplate and the
generally accepted that deformities that correct in exten- horizontal plane), C2 slope (C2S) (angle between the C2
sion may be successfully treated with posterior-only ap- inferior endplate and the horizontal plane), C2–7 cervical
proaches,3 but posterior-based osteotomy may also permit lordosis (CL), cSVA, and T1S minus CL (T1S-CL) (Fig.
significant correction of even rigid deformities.7 Given the 1). Radiographic measurements on preoperative ELXR
lack of clear guidelines for surgical approach and oste- and neutral lateral radiography were compared with those
otomy grade for CSD correction, this study was conducted on 3-month postoperative radiography. Autocorrection of
to assess the relationship between choice of surgical pro- CSD between baseline ELXR and baseline lateral radiog-
cedure (approach and osteotomy type) and preoperative raphy was determined on the basis of a previously vali-
cervical spine flexibility among a group of patients treated dated TS1-CL threshold of 17°;9,13 TS1-CL is analogous
by highly experienced deformity surgeons at multiple cen- to pelvic incidence minus lumbar lordosis in the thora-
ters. We also evaluated whether preoperative extension columbar spine. The t-test and chi-square test were used
lateral radiography (ELXR) predicted final postoperative to evaluate associations between preoperative ELXR pa-
cervical alignment. We hypothesized that choice of surgi- rameters, osteotomy type, and surgical approach. Analysis
cal procedure was driven by preoperative flexibility of the was performed using SPSS version 20.0 (IBM Corp.), with
cervical spine. the level of significance defined as p = 0.05.

Methods Results
The medical records of patients who were consecutive- Of 164 patients who underwent CSD surgery, 106 met
ly enrolled in a prospective, multicenter cervical deformi- inclusion criteria. The mean (range) patient age was 60
ty database were retrospectively reviewed. IRB approval (30–82) years, 58% of patients were female, and 43.4% of
was obtained from each participating site prior to study patients had previously undergone cervical spine surgery.
initiation. All patients > 18 years old who underwent CSD Osteotomy was performed on 92 patients (86.8%), with

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TABLE 3. Comparison of radiographic parameters on

preoperative ELXR according to osteotomy grades, as described
by Ames et al.7
Parameter Grade 1–2 Grade 5–7 p Value
T1S, ° 23.06 35.47 0.021
T1S-CL, ° 20.91 36.29 0.033
cSVA, ° 24.67 48.35 <0.001
C2S, ° 18.69 37.47 0.008
Mean values are shown unless indicated otherwise.

osteotomy (Table 3). Subsequent analysis revealed that the

anterior approach was chosen over the posterior approach
when patients had more normal radiographic alignment
in extension, including lower T1S (mean 21.17° vs 31.59°,
p = 0.018), cSVA (11.19° vs 36.45°, p < 0.001), T1S-CL
(13.68° vs 28.13°, p = 0.014), and C2S (8.49° vs 28.29°,
p < 0.001) (Table 4). Patients with larger than normal
T1S-CL (> 17°) on preoperative ELXR were more likely
to undergo a posterior approach procedure (46.77% vs
36.36%, p = 0.033). Patients who achieved autocorrection
in T1S-CL were significantly more likely to undergo only
an anterior approach procedure, with a likelihood ratio of
6.758 (Table 5). Overall, surgery resulted in statistically
significant changes between preoperative and 3-month
neutral lateral radiography for all radiographic parameters
(Table 6). However, 3-month postoperative lateral neutral
radiography and baseline ELXR were statistically similar
FIG. 1. Radiographic parameters of interest. A: T1S (angle between the
for TS1-CL (mean 26.04° vs 24.84°, p = 0.542) and C2S
T1 superior endplate and the horizontal plane). B: C2S (angle between (23.28° vs 22.88°, p = 0.839) (Table 6).
the C2 inferior endplate and the horizontal plane). C: C2–7 CL. D: cSVA.
T1S-CL is calculated using T1S and CL. Figure is available in color
online only.
Discussion
In 2013, Ames et al. published a cervical osteotomy
classification system with seven anatomical grades based
on extent of resection of soft tissue and bone.7 With in-
the following distribution according to grade: 1–2 (n = 58 creasing osteotomy grade, there is greater potential desta-
[63.0%]), 3–4 (18 [19.6%]), and 5–7 (16 [17.4%]). bilization and, in theory, greater degree of cervical defor-
Significant differences between baseline neutral lateral mity correction.7 We are aware of no other study that eval-
radiography and baseline ELXR were noted for all radio- uated the associations between specific preoperative plain
graphic parameters (Table 2). Preoperative ELXR demon- radiographic measurements and grade of osteotomy. Our
strated significantly lower T1S (mean 23.06° vs 35.47°, p = study utilized several well-studied radiographic param-
0.021), T1S-CL (20.91° vs 36.29°, p = 0.033), cSVA (24.67° eters of cervical and cervicothoracic deformity, including
vs 48.35°, p < 0.001), and C2S (18.69° vs 37.47°, p = 0.008) T1S, T1S-CL, cSVA, and C2S. T1S and cSVA are used
for patients who underwent grade 1–2 osteotomy in com- to evaluate overall sagittal balance of the cervicothoracic
parison with those of patients who underwent grade 5–7 spine.12,14 T1S-CL is analogous to pelvic incidence minus
lumbar lordosis (PI-LL) mismatch for thoracolumbar de-
formity, and the mean ± SD normal T1S-CL is reportedly
TABLE 2. Comparison of baseline deformity parameters between
neutral lateral radiography and ELXR
TABLE 4. Comparison of radiographic parameters on
Parameter LXR ELXR Difference p Value
preoperative ELXR according to surgical approach
C2S, ° 38.579 ± 19.626 22.876 ± 21.089 15.703 <0.001
Parameter Anterior Posterior p Value
T1S, ° 28.634 ± 15.663 25.098 ± 15.529 3.536 <0.001
C2–7 CL, ° −10.666 ± 17.677 0.260 ± 19.658 −10.926 <0.001 T1S, ° 21.17 31.59 0.018
cSVA, ° 37.245 ± 20.510 27.682 ± 21.900 9.563 <0.001 T1S-CL, ° 13.68 28.13 0.014
T1S-CL, ° 39.299 ± 18.494 24.839 ± 19.570 14.460 <0.001 cSVA, ° 11.19 36.45 <0.001
C2S, ° 8.49 28.29 <0.001
LXR = lateral radiography.
Values are shown as mean ± SD unless indicated otherwise. Mean values are shown unless indicated otherwise.

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TABLE 5. Autocorrection of T1S-CL on baseline ELXR to < 17° TABLE 6. Comparison of radiographic parameters on
and resulting surgical approach preoperative and 3-month postoperative lateral neutral
radiography and ELXR
Combined Anterior
Correction Anterior Posterior & Posterior p Value Neutral ELXR p
No 8 29 25 Parameter Preop 3-mo p Value Preop 3-mo p Value Value*
0.033
Yes 15 16 13 T1S, ° 28.63 34.45 <0.001 25.10 34.45 <0.001 <0.001
Values represent the number of patients unless indicated otherwise. T1S-CL, ° 39.30 26.04 <0.001 24.84 26.04 0.542 0.162
cSVA, ° 37.25 30.95 <0.001 27.58 30.95 0.053 <0.001
C2S, ° 38.58 23.28 <0.001 22.88 23.28 0.839 0.150
16.5° ± 2°.8,13 Additionally, C2S may serve as a singular
marker of cervical deformity, and Protopsaltis et al. have Mean values are shown unless indicated otherwise.
* Comparison of preoperative ELXR with 3-month postoperative radiography.
validated it as a mathematical approximation of T1S-CL.15
The results of this study showed that grade 1–2 oste-
otomy was associated with lower CSD severity. Specifi-
cally, T1S, T1S-CL, cSVA, and C2S were all significantly This study was limited by its retrospective design and
lower in the grade 1–2 cohort in comparison with those of susceptibility to surgeon bias in treatment selection. For
the grade 5–7 cohort. Specifically, patients who achieved example, the decision to perform an anterior or posterior
autocorrection of T1S-CL to less than 17° on preoperative approach, or osteotomy type, may have been influenced
ELXR were significantly more likely to undergo surgery by the surgeons’ practice preferences as much as the
with an anterior approach alone. Understanding this corre- preoperative radiographic parameters. Surgeon bias and
lation is helpful in preoperative planning for CSD correc- familiarity with anterior versus posterior approaches, as
tion. In particular, when the abovementioned radiographic well as osteotomy types, may have influenced approach
parameters on preoperative ELXR are low, lower-grade and osteotomy type as much as preoperative correction
osteotomy is likely sufficient to achieve satisfactory post- on ELXR, and this is a limitation inherent to the retro-
operative alignment. This is important because limiting spective nature of this study. To confirm the utility of
the extent of osteotomy may help maximize postoperative preoperative ELXR, future prospective studies should be
stability and minimize potential morbidity and complica- performed with preoperative ELXR used to determine
tions associated with correction of CSD. Conversely, pa- the specific approach and osteotomy for each patient. We
tients with preoperative radiographic parameters indicat- were also unable to account for other factors that may
ing greater deformity severity may require higher grade have influenced choice of approach and osteotomy, such
osteotomy for optimal deformity correction. However, it is as perceived wound-healing ability, obesity, or prior cer-
important to note that higher grade osteotomy requiring a vical spine procedures. Furthermore, we were unable to
combined anterior and posterior approach may not be fea- include functional outcomes or complications data, be-
sible in patients with severe, rigid chin-on-chest deformity. cause these were unavailable. Nevertheless, increased
Lower T1S, T1S-CL, cSVA, and C2S were also associ- use of ELXR for preoperative planning may help reduce
ated with use of an anterior-only approach (Fig. 2). This unnecessary utilization of osteotomy, in turn reducing
correlates with the expected degree of correction with procedural morbidity and complications while improving
anterior osteotomy, because posterior-based, higher grade functional outcomes. Additionally, although our patient
osteotomy (e.g., opening wedge osteotomy, closing wedge population was relatively small, our study size was suf-
osteotomy, and complete vertebral column resection) is ficient to detect significant differences in radiographic
commonly utilized for more severe CSD.7 The relation- parameters on preoperative ELXR between patients who
ships between surgical approach and osteotomy grade underwent different osteotomy types. Our study popu-
with preoperative ELXR established in this study led us to lation was likely limited by our strict inclusion criteria,
the following recommendations: grade 1–2 osteotomy via which specified deformities limited to the cervical or cer-
anterior-only approach may be sufficient for CSD patients vicothoracic spine. However, the generalizability of our
with greater neck extension and thus greater cervical flex- data was increased through the use of a multicenter data-
ibility, as demonstrated by lower T1S, T1S-CL, cSVA, and base that included multiple surgeons.
C2S on preoperative ELXR. Higher grade osteotomy via
a posterior approach may be necessary for CSD patients
with less neck extension and cervical flexibility, as dem- Conclusions
onstrated by higher T1S, T1S-CL, cSVA, and C2S on pre- Preoperative ELXR demonstrated a significant asso-
operative ELXR. ciation with surgeons’ choice of approach and osteotomy
Preoperative ELXR not only helps surgeons decide sur- grade. CSD patients with greater neck extension were
gical approach and osteotomy, but it also helps predict final more likely to undergo high-grade osteotomy and poste-
postoperative cervical alignment. In particular, T1S-CL rior-only approach procedures. Findings on preoperative
and C2S were similar on preoperative ELXR and 3-month ELXR were statistically similar to those on 3-month post-
postoperative lateral radiography (Fig. 2). Thus, preopera- operative neutral lateral radiography and may be used to
tive cSVA with the neck at full extension provides the best predict final cervical alignment. ELXR is a critical align-
estimate of postoperative alignment. This is especially use- ment tool in CSD correction, and its use is strongly rec-
ful for preoperative planning and patient counseling. ommended as a part of the preoperative surgical planning

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FIG. 2. A: A preoperative lateral neutral radiograph demonstrating upper CSD with T1S of 28°, cSVA of 38.5 mm, T1S-CL of 37°,
and C2S of 23°. B: An extension lateral radiograph showing that T1S improved to 16°, cSVA to 19.8 mm, T1S-CL to 3°, and C2S to
0°. C: A postoperative lateral neutral radiograph after C4–7 anterior cervical discectomy and fusion showing T1S of 17°, cSVA of
22.1 mm, T1S-CL of 3°, and C2S of 8°.

because it helps determine approach, osteotomy grade, lizing a novel angle δ to describe the relationship among T1
and final alignment. vertebral body slope, cervical lordosis, and cervical sagittal
alignment. Neurosurgery. 2020;​86(3):​446–451.
11. Virk S, Passias P, Lafage R, et al. Intraoperative alignment
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Smith-Petersen osteotomy versus pedicle subtraction oste- Disclosures
otomy versus anterior-posterior osteotomy types for the cor- The International Spine Study Group is funded through research
rection of cervical spine deformities. Spine (Phila Pa 1976). grants from DePuy Synthes. Mr. Lafage holds stock options in
2015;​40(3):​143–146. Nemaris, Inc. Dr. Mundis is a consultant for NuVasive, Viseon,
7. Ames CP, Smith JS, Scheer JK, et al. A standardized nomen- and Carlsmed; receives personal fees, holds a patent with, and
clature for cervical spine soft-tissue release and osteotomy receives royalties from K2M/Stryker; is a consultant for and owns
for deformity correction:​clinical article. J Neurosurg Spine. stock in SeaSpine; and owns stock in Alphatec. Dr. Eastlack
2013;​19(3):​269–278. receives personal fees and royalties from, is a consultant for, and
8. Staub BN, Lafage R, Kim HJ, et al. Cervical mismatch:​the owns stock in Aesculap; owns stock in and is a consultant for
normative value of T1 slope minus cervical lordosis and its Alphatec; owns stock in and holds a patent with Spine Innovation;
ability to predict ideal cervical lordosis. J Neurosurg Spine. is a consultant for and receives clinical or research support for the
2018;​30(1):​31–37. study described from Medtronic; is a consultant for and holds a
9. Protopsaltis TS, Ramchandran S, Hamilton DK, et al. Analy- patent with Stryker; is a consultant for Carevature; is a consultant
sis of successful versus failed radiographic outcomes after for, receives royalties from, and owns stock in SI Bone; receives
cervical deformity surgery. Spine (Phila Pa 1976). 2018;​ royalties from and holds a patent with Globus Medical; is a con-
43(13):​E773–E781. sultant for, receives royalties from, owns stock in, receives fellow-
10. Goldschmidt E, Angriman F, Agarwal N, et al. A new piece ship and research grants from, and receives clinical or research
of the puzzle to understand cervical sagittal alignment:​uti- support for the study described from NuVasive; is a consultant

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for, receives royalties from, owns stock in, receives fellowship and NuVasive; receives grants, receives fellowship funding from, and
research grants from, and receives clinical or research support receives non–study-related clinical or research support from AO
for the study described from SeaSpine; is on the speakers bureau Spine; receives non–study-related clinical or research support
of Radius; and is a consultant for Spinal Elements. Dr. Bess is a and clinical or research support for the study described from
consultant for, holds a patent with, is on the speakers bureau of, ISSG; serves on the editorial boards of Neurosurgery, Operative
receives royalties from, and receives non–study-related clinical or Neurosurgery, and Journal of Neurosurgery: Spine; owns stock
research support from K2M/Stryker; receives non–study-related in Alphatec; and serves on the board of directors of the Scoliosis
clinical or research support from Globus; receives non–study- Research Society. Dr. Passias receives nonfinancial support from
related clinical or research support from SI Bone; receives non– Allosource; receives grants from the Cervical Spine Research
study-related clinical or research support from SeaSpine; receives Society; and receives personal fees from Globus Medical, Medi-
non–study-related clinical or research support from ISSGF; is crea, Royal Biologics, SpineWave, Terumo; and Zimmer Biomet.
a consultant for Mirus; owns stock in Carlsmed; owns stock in Dr. Gupta receives personal fees and royalties from and is a
Progenerative Medical; receives grants, non–study-related clinical consultant for DePuy Synthes; receives royalties from Innomed;
or research support, and clinical or research support for the study is a consultant for and receives personal fees from Medtronic;
described from DePuy Synthes; receives grants and non–study- receives royalties, is a consultant for, and receives personal fees
related clinical or research support from Medtronic; and receives from Globus Medical; owns stock in Johnson & Johnson; owned
grants, receives royalties from, and holds a patent with NuVasive. stock in Proctor and Gamble; receives nonfinancial support and
Dr. Burton receives grants, personal fees, royalties, and research travel expenses from the Scoliosis Research Society; receives non-
support from DePuy Synthes; receives research support from and financial support from Medicrea; receives nonfinancial support
owns stock in Progenerative Medical; receives research support from Mizuho; receives nonfinancial support from and previously
from Bioventus; is a consultant for and receives royalties from worked as a consultant for Alphatec; and receives honoraria from
Globus; and receives research support from Pfizer. Dr. Ames is AO Spine. Dr. Lafage is a consultant for Globus Medical; receives
an employee of UCSF; receives royalties from Stryker; receives royalties from NuVasive; owns stock in Nemaris; and has received
royalties from Biomet Zimmer Spine; receives royalties from, personal fees from DePuy Synthes, Implanet, Johnson & Johnson,
is a consultant for, and receives research funding from DePuy and K2M. Dr. Klineberg is a consultant for DePuy Synthes Spine,
Synthes; receives royalties from NuVasive; receives royalties from Stryker, and Medicrea/Medtronic; has received a fellowship grant
Next Orthosurgical; receives royalties from and has worked as for University of California, Davis; and has received honoraria
a consultant for K2M; receives royalties from Stryker; receives from AO Spine.
royalties from Medicrea; is a consultant for Medtronic; is as a
consultant for Medicrea; receives research funding from Titan Author Contributions
Spine; receives research funding from and serves on the executive Conception and design: Le, R Lafage, Klineberg. Acquisition of
committee of ISSG; serves on the editorial board of Operative data: Le, R Lafage, Mundis, Eastlack, Bess, Burton, Ames, Smith,
Neurosurgery; receives grant funding from SRS; and is the direc- Passias, Gupta, V Lafage, Klineberg. Analysis and interpretation
tor of Global Spine Analytics. Dr. Smith receives personal fees of data: all authors. Drafting the article: Le, Wick, Klineberg.
from, is a consultant for, and receives non–study-related clinical Critically revising the article: all authors. Reviewed submitted
or research support from Stryker; receives personal fees from version of manuscript: all authors. Approved the final version of
and is a consultant for Cerapedics; receives personal fees from the manuscript on behalf of all authors: Le. Statistical analysis: R
and is a consultant for Carlsmed; receives personal fees from, Lafage, V Lafage. Administrative/technical/material support: Le.
is a consultant for, and receives royalties from Zimmer Biomet; Study supervision: Le, Klineberg.
receives personal fees from NuVasive; receives personal fees and
royalties from Thieme; receives personal fees from, is a consul- Correspondence
tant for, receives grants from, receives non–study-related clinical
or research support from, and receives clinical or research sup- Hai V. Le: University of California, Davis, Sacramento, CA.
port for the study described from DePuy Synthes; receives grants [email protected].
from, is a consultant for, receives royalties from, owns stock in,
and receives non–study-related clinical or research support from

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