{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T12:30:08Z","timestamp":1783427408798,"version":"3.54.6"},"reference-count":27,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,12,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The objective was to discern whether the cranial sagittal vertical axis (CrSVA) can best predict the trajectory of patient-reported outcome measures (PROMs) at 2 years postoperatively.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>This was a retrospective cohort study of prospectively collected adult spinal deformity patient data. CrSVA relative to the sacrum, hip (CrSVA-H), knee, and ankle was measured as the horizontal distance to the vertical plumb line from the nasion-inion midpoint, with positive values indicating an anterior cranium. Standard sagittal alignment parameters were also collected. Outcome variables were PROMs as measured by Scoliosis Research Society-22r questionnaire (SRS-22r) total and subdomain scores and the Oswestry Disability Index. Pearson\u2019s correlation coefficients and univariate regressions were performed to investigate associations between predictors and PROMs. Two conceptual multivariable linear regression models for each 2-year outcome measure were built after adjusting for the impact of preoperative SRS-22r scores. Model 1 assessed pre- and postoperative alignment only relative to C2 and C7, while model 2 assessed alignment relative to C2 and C7 as well as the cranium.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>There was a total of 363 patients with 2 years of radiographic and PROM follow-up (68.0% female, mean [standard error of the mean] age 60.8 [0.78] years, BMI 27.5 [0.29], and total number of instrumented levels 12.8 [0.22]). CrSVA measures were significantly associated with the 2-year SRS-22r total and subdomain scores. In univariate regression, revision surgery, number of prior surgeries, frailty, BMI, total number of osteotomies, and lower baseline total SRS-22r score as well as postoperative sagittal alignment were significantly associated with worse 2-year SRS-22r scores. In multivariable regression, after adjusting for baseline SRS-22r scores, greater preoperative C2 to sacrum sagittal vertical axis (SVA) and C7 SVA were found to be the only independent predictors of 2-year total SRS-22r score (\u03b2 = \u22120.011 [p = 0.0026] and \u03b2 = 0.009 [p = 0.0211], respectively) when alignment was considered only relative to C2. However, in the subsequent model, CrSVA-H replaced C7 SVA as the independent factor driving postoperative SRS-22r total scores (\u03b2 = \u22120.006, p &lt; 0.0001). That is, when the model included alignment relative to the cranium, C2, and C7, greater or more anterior CrSVA-H resulted in worse SRS-22r scores, while smaller or more posterior CrSVA-H resulted in better scores. Similar models for subdomains again found CrSVA-H to be the best predictor of function (\u03b2 = \u22120.0095, p &lt; 0.0001), pain (\u03b2 = \u22120.0091, p &lt; 0.0001), self-image (\u03b2 = \u22120.0084, p = 0.0004), and mental health (\u03b2 = \u22120.0059, p = 0.0026).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>In multivariable regression, C7 SVA was supplanted by CrSVA-H alignment as a significant, independent predictor of 2-year SRS-22r scores in patients with adult spinal deformity and should be considered as one of the standard postoperative sagittal alignment target goals.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2024.5.spine231187","type":"journal-article","created":{"date-parts":[[2024,8,24]],"date-time":"2024-08-24T01:58:04Z","timestamp":1724464684000},"page":"774-783","source":"Crossref","is-referenced-by-count":6,"title":["Cranial sagittal vertical axis to the hip as the best sagittal alignment predictor of patient-reported outcomes at 2 years postoperatively in adult spinal deformity surgery"],"prefix":"10.3171","volume":"41","author":[{"given":"Christopher S.","family":"Lai","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarthak","family":"Mohanty","sequence":"additional","affiliation":[{"name":"Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fthimnir M.","family":"Hassan","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline E.","family":"Taber","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaques L.","family":"Williams","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan J.","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zeeshan M.","family":"Sardar","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald A.","family":"Lehman","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence G.","family":"Lenke","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"10193","key":"b1","series-title":"Lancet","first-page":"160","article-title":"Adult spinal deformity","volume":"394","author":"Diebo BG","year":"2019","unstructured":"Diebo BG, Shah NV, Boachie-Adjei O,  Adult spinal deformity. Lancet. 2019;394(10193):160\u2013172."},{"issue":"20","key":"b2","series-title":"Spine (Phila Pa 1976)","first-page":"2171","article-title":"Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study","volume":"34","author":"Bridwell KH","year":"2009","unstructured":"Bridwell KH, Glassman S, Horton W,  Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976). 2009;34(20):2171\u20132178."},{"issue":"20","key":"b3","series-title":"Spine (Phila Pa 1976)","first-page":"2165","article-title":"Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up","volume":"34","author":"Li G","year":"2009","unstructured":"Li G, Passias P, Kozanek M,  Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine (Phila Pa 1976). 2009;34(20):2165\u20132170."},{"issue":"18","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"2024","article-title":"The impact of positive sagittal balance in adult spinal deformity","volume":"30","author":"Glassman SD","year":"2005","unstructured":"Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):2024\u20132029."},{"issue":"6","key":"b5","series-title":"Spine (Phila Pa 1976)","first-page":"682","article-title":"Correlation of radiographic parameters and clinical symptoms in adult scoliosis","volume":"30","author":"Glassman SD","year":"2005","unstructured":"Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976). 2005;30(6):682\u2013688."},{"issue":"4","key":"b6","series-title":"Spine (Phila Pa 1976)","first-page":"387","article-title":"Adult scoliosis: a quantitative radiographic and clinical analysis","volume":"27","author":"Schwab FJ","year":"2002","unstructured":"Schwab FJ, Smith VA, Biserni M, Gamez L, Farcy JPC, Pagala M. Adult scoliosis: a quantitative radiographic and clinical analysis. Spine (Phila Pa 1976). 2002;27(4):387\u2013392."},{"issue":"17","key":"b7","series-title":"Spine (Phila Pa 1976)","first-page":"E599","article-title":"Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity","volume":"34","author":"Lafage V","year":"2009","unstructured":"Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599\u2013E606."},{"issue":"15","key":"b8","series-title":"Spine (Phila Pa 1976)","first-page":"E519","article-title":"Can C7 plumbline and gravity line predict health related quality of life in adult scoliosis?","volume":"34","author":"Mac-Thiong JM","year":"2009","unstructured":"Mac-Thiong JM, Transfeldt EE, Mehbod AA,  Can C7 plumbline and gravity line predict health related quality of life in adult scoliosis? Spine (Phila Pa 1976). 2009;34(15):E519\u2013E527."},{"issue":"13","key":"b9","series-title":"Spine (Phila Pa 1976)","first-page":"E803","article-title":"Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis","volume":"38","author":"Schwab FJ","year":"2013","unstructured":"Schwab FJ, Blondel B, Bess S,  Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976). 2013;38(13):E803\u2013E812."},{"issue":"13","key":"b10","series-title":"Spine (Phila Pa 1976)","first-page":"1535","article-title":"Center of gravity and radiographic posture analysis: a preliminary review of adult volunteers and adult patients affected by scoliosis","volume":"30","author":"El Fegoun AB","year":"2005","unstructured":"El Fegoun AB, Schwab F, Gamez L, Champain N, Skalli W, Farcy JP. Center of gravity and radiographic posture analysis: a preliminary review of adult volunteers and adult patients affected by scoliosis. Spine (Phila Pa 1976). 2005;30(13):1535\u20131540."},{"issue":"7","key":"b11","series-title":"Spine (Phila Pa 1976)","first-page":"592","article-title":"Correlation of radiographic and functional measurements in patients who underwent primary scoliosis surgery in adult age","volume":"37","author":"S\u00e1nchez-Mariscal F","year":"2012","unstructured":"S\u00e1nchez-Mariscal F, Gomez-Rice A, Izquierdo E, Pizones J, Z\u00fa\u00f1iga L, Alvarez-Gonz\u00e1lez P. Correlation of radiographic and functional measurements in patients who underwent primary scoliosis surgery in adult age. Spine (Phila Pa 1976). 2012;37(7):592\u2013598."},{"issue":"8","key":"b12","series-title":"Eur Spine J","first-page":"2167","article-title":"The cranial sagittal vertical axis (CrSVA) is a better radiographic measure to predict clinical outcomes in adult spinal deformity surgery than the C7 SVA: a monocentric study","volume":"26","author":"Kim YC","year":"2017","unstructured":"Kim YC, Lenke LG, Lee SJ, Gum JL, Wilartratsami S, Blanke KM. The cranial sagittal vertical axis (CrSVA) is a better radiographic measure to predict clinical outcomes in adult spinal deformity surgery than the C7 SVA: a monocentric study. Eur Spine J. 2017;26(8):2167\u20132175."},{"issue":"3","key":"b13","series-title":"J Neurosurg Spine","first-page":"372","article-title":"Novel radiographic parameters for the assessment of total body sagittal alignment in adult spinal deformity patients","volume":"31","author":"Kim YC","year":"2019","unstructured":"Kim YC, Cui JH, Kim KT,  Novel radiographic parameters for the assessment of total body sagittal alignment in adult spinal deformity patients. J Neurosurg Spine. 2019;31(3):372\u2013379."},{"issue":"5","key":"b14","series-title":"Spine (Phila Pa 1976)","first-page":"593","article-title":"Refinement of the SRS-22 health-related quality of life questionnaire function domain","volume":"31","author":"Asher MA","year":"2006","unstructured":"Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 health-related quality of life questionnaire function domain. Spine (Phila Pa 1976). 2006;31(5):593\u2013597."},{"issue":"3","key":"b15","series-title":"J Neurosurg Spine","first-page":"301","article-title":"Outcomes and reoperation rates of adult spinal deformity patients with baseline sagittal malalignment based on the cranial axis to the hip at 2 years postoperatively","volume":"39","author":"Mohanty S","year":"2023","unstructured":"Mohanty S, Lai C, Mikhail C,  Outcomes and reoperation rates of adult spinal deformity patients with baseline sagittal malalignment based on the cranial axis to the hip at 2 years postoperatively. J Neurosurg Spine. 2023;39(3):301\u2013310."},{"issue":"10","key":"b16","series-title":"Spine (Phila Pa 1976)","first-page":"E584","article-title":"Standing balance and compensatory mechanisms in patients with adult spinal deformity","volume":"42","author":"Yagi M","year":"2017","unstructured":"Yagi M, Kaneko S, Yato Y, Asazuma T. Standing balance and compensatory mechanisms in patients with adult spinal deformity. Spine (Phila Pa 1976). 2017;42(10):E584\u2013E591."},{"issue":"25","key":"b17","series-title":"Spine (Phila Pa 1976)","first-page":"2224","article-title":"Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery","volume":"35","author":"Schwab F","year":"2010","unstructured":"Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010;35(25):2224\u20132231."},{"issue":"9","key":"b18","series-title":"Spine (Phila Pa 1976)","first-page":"653","article-title":"Full-body analysis of age-adjusted alignment in adult spinal deformity patients and lower-limb compensation","volume":"42","author":"Jalai CM","year":"2017","unstructured":"Jalai CM, Cruz DL, Diebo BG,  Full-body analysis of age-adjusted alignment in adult spinal deformity patients and lower-limb compensation. Spine (Phila Pa 1976). 2017;42(9):653\u2013661."},{"issue":"4","key":"b19","series-title":"J Neurosurg Spine","first-page":"494","article-title":"Global sagittal axis: a step toward full-body assessment of sagittal plane deformity in the human body","volume":"25","author":"Diebo BG","year":"2016","unstructured":"Diebo BG, Oren JH, Challier V,  Global sagittal axis: a step toward full-body assessment of sagittal plane deformity in the human body. J Neurosurg Spine. 2016;25(4):494\u2013499."},{"issue":"6","key":"b20","series-title":"Spine (Phila Pa 1976)","first-page":"484","article-title":"Redefining global spinal balance: normative values of cranial center of mass from a prospective cohort of asymptomatic individuals","volume":"38","author":"Sugrue PA","year":"2013","unstructured":"Sugrue PA, McClendon J Jr, Smith TR,  Redefining global spinal balance: normative values of cranial center of mass from a prospective cohort of asymptomatic individuals. Spine (Phila Pa 1976). 2013;38(6):484\u2013489."},{"issue":"2","key":"b21","series-title":"J Neurosurg Spine","first-page":"153","article-title":"How the neck affects the back: changes in regional cervical sagittal alignment correlate to HRQOL improvement in adult thoracolumbar deformity patients at 2-year follow-up","volume":"23","author":"Protopsaltis TS","year":"2015","unstructured":"Protopsaltis TS, Scheer JK, Terran JS,  How the neck affects the back: changes in regional cervical sagittal alignment correlate to HRQOL improvement in adult thoracolumbar deformity patients at 2-year follow-up. J Neurosurg Spine. 2015;23(2):153\u2013158."},{"issue":"4","key":"b22","series-title":"J Neurosurg Spine","first-page":"300","article-title":"Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy","volume":"17","author":"Smith JS","year":"2012","unstructured":"Smith JS, Shaffrey CI, Lafage V,  Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy. J Neurosurg Spine. 2012;17(4):300\u2013307."},{"issue":"2","key":"b23","series-title":"J Neurosurg Spine","first-page":"141","article-title":"Cervical spine alignment, sagittal deformity, and clinical implications: a review","volume":"19","author":"Scheer JK","year":"2013","unstructured":"Scheer JK, Tang JA, Smith JS,  Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine. 2013;19(2):141\u2013159."},{"issue":"8","key":"b24","series-title":"Spine J","first-page":"1756","article-title":"Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up","volume":"15","author":"Passias PG","year":"2015","unstructured":"Passias PG, Soroceanu A, Scheer J,  Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up. Spine J. 2015;15(8):1756\u20131763."},{"issue":"3","key":"b25","series-title":"J Neurosurg Spine","first-page":"410","article-title":"Evaluation of coronal alignment from the skull using the novel orbital-coronal vertical axis line","volume":"37","author":"Zuckerman SL","year":"2022","unstructured":"Zuckerman SL, Chanbour H, Hassan FM,  Evaluation of coronal alignment from the skull using the novel orbital-coronal vertical axis line. J Neurosurg Spine. 2022;37(3):410\u2013419."},{"issue":"3","key":"b26","series-title":"J Neurosurg Spine","first-page":"408","article-title":"Factors influencing patient satisfaction after adult scoliosis and spinal deformity surgery","volume":"31","author":"Hayashi K","year":"2019","unstructured":"Hayashi K, Boissi\u00e8re L, Guevara-Villaz\u00f3n F,  Factors influencing patient satisfaction after adult scoliosis and spinal deformity surgery. J Neurosurg Spine. 2019;31(3):408\u2013417."},{"issue":"1","key":"b27","series-title":"Clin Spine Surg","first-page":"E32","article-title":"Is the cranial sagittal vertical axis (Cr-SVA) a better midterm predictor of clinical results than C7-SVA in adult patients operated on spinal deformity after a minimum 2-year follow-up?","volume":"34","author":"Gomez-Rice A","year":"2021","unstructured":"Gomez-Rice A, Madrid C, Izquierdo E, Marco-Mart\u00ednez F, Tresguerres JAF, Sanchez-Mariscal F. Is the cranial sagittal vertical axis (Cr-SVA) a better midterm predictor of clinical results than C7-SVA in adult patients operated on spinal deformity after a minimum 2-year follow-up?. Clin Spine Surg. 2021;34(1):E32\u2013E38."}],"container-title":["Journal of Neurosurgery: Spine"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/41\/6\/article-p774.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/41\/6\/article-p774.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/41\/6\/article-p774.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,6]],"date-time":"2024-12-06T13:20:55Z","timestamp":1733491255000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/41\/6\/article-p774.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,1]]},"references-count":27,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.3171\/2024.5.spine231187","relation":{},"ISSN":["1547-5654"],"issn-type":[{"value":"1547-5654","type":"print"}],"subject":[],"published":{"date-parts":[[2024,12,1]]}}}