“Reverse roussouly”: cervicothoracic curvature ratios define characteristic shapes in adult cervical deformity

Peter G. Passias, Katherine E. Pierce, Tyler Williamson, Shaleen Vira, Stephane Owusu-Sarpong, Ravinderjit Singh, Oscar Krol, Lara Passfall, Nicholas Kummer, Bailey Imbo, Rachel Joujon-Roche, Peter Tretiakov, Kevin Moattari, Matthew V. Abola, Waleed Ahmad, Sara Naessig, Salman Ahmad, Vivek Singh, Bassel Diebo, Virginie Lafage

Research output: Contribution to journalArticlepeer-review


Purpose: To investigate normal curvature ratios of the cervicothoracic spine and to establish radiographic thresholds for severe myelopathy and disability, within the context of shape. Methods: Adult cervical deformity (CD) patients undergoing cervical fusion were included. C2-C7 Cobb angle (CL) and thoracic kyphosis (TK), using T2-T12 Cobb angle, were used as a ratio, ranging from −1 to + 1. Pearson bivariate r and univariate analyses analyzed radiographic correlations and differences in myelopathy(mJOA > 14) or disability(NDI > 40) across ratio groups. Results: Sixty-three CD patients included. Regarding CL:TK ratio, 37 patients had a negative ratio and 26 patients had a positive ratio. A more positive CL:TK correlated with increased TS-CL(r = 0.655, p = < 0.001)and mJOA(r = 0.530, p = 0.001), but did not correlate with cSVA/SVA or NDI scores. A positive CL:TK ratio was associated with moderate disability(NDI > 40)(OR: 7.97[1.22–52.1], p = 0.030). Regression controlling for CL:TK ratio revealed cSVA > 25 mm increased the odds of moderate to severe myelopathy and cSVA > 30 mm increased the odds of significant neck disability. Lastly, TS-CL > 29 degrees increased the odds of neck disability by 4.1 × with no cutoffs for severe mJOA(p > 0.05). Conclusions: Cervical deformity patients with an increased CL:TK ratio had higher rates of moderate neck disability at baseline, while patients with a negative ratio had higher rates of moderate myelopathy clinically. Specific thresholds for cSVA and TS-CL predicted severe myelopathy or neck disability scores, regardless of baseline neck shape. A thorough evaluation of the cervical spine should include exploration of relationships with the thoracic spine and may better allow spine surgeons to characterize shapes and curves in cervical deformity patients.

Original languageEnglish (US)
JournalEuropean Spine Journal
StateAccepted/In press - 2022


  • Cervical deformity
  • Cervicothoracic
  • Myelopathy
  • Roussouly
  • Secondary driver
  • Spine

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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