Cervical Alignment and Proximal and Distal Junctional Failure in Posterior Cervical Fusion: A Multicenter Comparison of 2 Surgical Approaches

Study Design: This was a multicenter retrospective cohort study. Objective: The purpose of this study was to compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2 to T2 to patients with constructs extending from C3 to T1. Summary of Background Data: Limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. Methods: A multicenter retrospective cohort study of patients who underwent PCF between 2012 and 2020 was performed. Surgical and radiographic outcomes were compared between those who had C3-T1 or C2-T2 constructs. Results: A total of 155 patients were included in the study (C2-T2: 106 patients, C3-T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2-T2 (93%) than the C3-T1 (80%, P=0.040) cohort. When comparing the C2-T2 to the C3-T1 cohort, the C3-T1 cohort had a significantly greater rate of proximal junctional failure (2% vs. 10%, P=0.006), distal junctional failure (1% vs. 20%, P<0.001) and distal screw loosening (4% vs. 15%, P=0.02). Although ΔC2-C7 sagittal vertical axis increased significantly in both cohorts (C2-T2: 6.2 mm, P=0.04; C3-T1: 8.4 mm, P<0.001), correction did not significantly differ between groups (P=0.32). The C3-T1 cohort had a significantly greater increase in ΔC2 slope (8.0 vs. 3.1 degrees, P=0.03) and ΔC0-C2 Cobb angle (6.4 vs. 1.2 degrees, P=0.04). Conclusion: In patients undergoing PCF, a C2-T2 construct demonstrated lower rates of pseudarthrosis, distal junctional failure, proximal junctional failure, and compensatory upper cervical hyperextension compared with a C3-T1 construct.