• Subaraman Ramchandran, Justin S Smith, Tamir Ailon, Eric Klineberg, Christopher Shaffrey, Virginie Lafage, Frank Schwab, Shay Bess, Alan Daniels, Justin K Scheer, Themi S Protopsaltis, Paul Arnold, Regis W Haid, Jens Chapman, Michael G Fehlings, Christopher P Ames, and AOSpine North America, International Spine Study Group.
• *Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;‡Department of Orthopaedic Surgery, University of California Davis Sacramento, California;§Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;¶Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado;‖Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island;#Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois;**Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas;‡‡Department of Neurosurgery, Atlanta Brain and Spine Care, Atlanta, Georgia;§§Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington;¶¶Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada;‖‖Department of Neurosurgery, University of California San Francisco, San Francisco, California.
• Neurosurgery. 2016 May 1; 78 (5): 717-24.

BackgroundUnderstanding the role of regional segments of the spine in maintaining global balance has garnered significant attention recently. Long-cassette radiographs (LCR) are necessary to evaluate global spinopelvic alignment. However, it is unclear how LCRs impact operative decision-making for cervical spine pathology.ObjectiveTo evaluate whether the addition of LCRs results in changes to respondents' operative plans compared to standard imaging of the involved cervical spine in an international survey of spine surgeons.MethodsFifteen cases (5 control cases with normal and 10 test cases with abnormal global alignment) of cervical pathology were presented online with a vignette and cervical imaging. Surgeons were asked to select a surgical plan from 6 options, ranging from the least (1 point) to most (6 points) extensive. Cases were then reordered and presented again with LCRs and the same surgical plan question.ResultsOne hundred fifty-seven surgeons completed the survey, of which 79% were spine fellowship trained. The mean response scores for surgical plan increased from 3.28 to 4.0 (P = .003) for test cases with the addition of LCRs. However, no significant changes (P = .10) were identified for the control cases. In 4 of the test cases with significant mid thoracic kyphosis, 29% of participants opted for the more extensive surgical options of extension to the mid and lower thoracic spine when they were provided with cervical imaging only, which significantly increased to 58.3% upon addition of LCRs.ConclusionIn planning for cervical spine surgery, surgeons should maintain a low threshold for obtaining LCRs to assess global spinopelvic alignment.

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