Efficacy analysis of anterior cervical fusion in the treatment of adolescent cervical kyphosis

Efficacy analysis of anterior cervical fusion in the treatment of adolescent cervical kyphosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy analysis of anterior cervical fusion in the treatment of adolescent cervical kyphosis Yahao Tian, Kaixu Yu, Feng Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2144854/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Surgical treatment remains a challenge for the treatment of adolescent cervical kyphosis, anterior cervical fusion (ACF) can correct kyphosis with small trauma. To study the efficacy and application scope of ACF for the treatment of adolescent cervical kyphosis. Methods Patients younger than 18 years old who had undergone anterior cervical discectomy/corpectomy and fusion (ACDF/ACCF) for cervical kyphosis from 2013.1 to 2020.12 in our hospital were retrospectively analyzed. The visual analogue scale (VAS) score for neck pain and neck disability index (NDI) were recorded at preoperative and the last follow-up. The C 2-7 Cobb angle, regional kyphosis angle (RKA), kyphosis index (KI), T1 slope (T1S), and C 2-7 sagittal vertical axis (C 2-7 SVA) were measured at preoperative, 1-week post-traction, 1-week postoperative, and last follow-up. Data were analyzed using the SPSS 25.0 software and p < 0.05 refers to a significant difference. Results A total of 11 patients were included, 6 with idiopathic, 1 with laminectomy, 2 with eosinophilic granuloma(EG), and 2 with trauma. All accepted skull-traction, the cervical kyphosis angle shows significant improvement at post-traction than preoperative. 9 patients accepted anterior cervical discectomy and fusion(ACDF), and 2 patients accepted anterior cervical corpectomy decompression and fusion (ACCF). The laminectomy patient occurred distal junctional kyphosis(DJK) at the last follow-up. The VAS score of neck pain and NDI at the last follow-up were smaller than preoperative (p<0.05). The cervical kyphosis angle shows significant improvement at postoperative and the last follow-up than preoperative and post-traction. There is no significant difference in cervical curvature between the postoperative and last follow-up. Conclusion ACF is suited to mild or moderate adolescent cervical kyphosis or can be corrected to mild or moderated by cervical traction. It is effective for improving clinical symptoms with small trauma. For patients with an intact posterior column, ACF is effective for restoring cervical lordosis. For patients without an intact posterior column, ACF-only is not enough, a combined approach should be considered and fused to the thoracic if necessary. Adolescent cervical kyphosis anterior cervical fusion laminectomy skull traction distal junctional kyphosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction There is no clear definition of cervical kyphosis, and previous studies have defined it with a C 2 − 7 Cobb angle ≥ 8° [ 1 ]. Etiology of cervical kyphosis includes tumor, trauma, idiopathic, medical origin and infection, etc. Clinical symptoms of cervical kyphosis include neck pain, neck kyphosis, numbness or pain in the limbs, limited flat vision, dyspnea, dysphagia, and disability[ 2 ]. Cervical traction and external fixation brace are commonly used for conservative treatment. For those who fail conservative treatment, surgical treatment remains a challenge in spinal surgery due to adolescent still growth and development. Posterior-only approach or the combined approach is highly invasive and disrupts the posterior column. Previous studies have confirmed that anterior cervical fusion (ACF) can achieve spinal decompression and cervical curvature correction with small trauma and beautiful incision[ 3 ]. Fewer studies have previously reported on ACF for adolescent cervical kyphosis, this study aims to evaluate the safety and effectiveness of this procedure. Materials And Methods Inclusion and exclusion criteria Inclusion criteria: Age ≤ 18 years; Neck pain, neurological dysfunction, progression of kyphosis, and ineffective conservative treatment more than 3 months; Accepted ACF treatment at our hospital and the surgery was performed by the same team. Complete medical records and imaging data. exclusion criteria: Adolescent idiopathic scoliosis(AIS); Ankylosing spondylitis; Motor neuron disease; Thoracic or lumbar spine disease. General information A total of 11 patients were included and followed up for more than 1 year. 6 with idiopathic, 1 with laminectomy, 2 with eosinophilic granuloma(EG), and 2 with trauma. Age 14.45 ± 2.62 years; Body Mass Index (BMI) 18.14 ± 3.18 kg/m 2 ; Course of disease 13.91 ± 14.59 months; Follow-up 42.45 ± 36.68 months. All patients received skull traction, mean of 9.82 ± 1.54 days, gradually increasing the traction weight to no more than 1/4 of their body weight (Table 1 ). Table 1 The general information patients Age (years) Gender (M/F) pathogenesis BMI (kg/m 2 ) ACF manners Traction time(days) complications 1 15 M idiopathic 18.73 3ACDF 11 2 17 M idiopathic 21.48 3ACDF 12 3 15 M idiopathic 15.78 4ACDF 7 4 16 M idiopathic 17.30 4ACDF 11 hoarseness 5 13 M idiopathic 19.78 4ACDF 7 6 17 M idiopathic 16.00 4ACDF 10 hoarseness 7 11 F laminectomy 14.81 3ACDF 10 DJK 8 10 F EG 17.35 ACCF 10 9 12 M EG 20.20 ACCF 10 10 15 M trauma 20.20 2ACDF 10 11 18 M trauma 13.62 2ACDF 10 Surgery procedure All operations were performed by the same group. Under general anesthesia, the patient was connected to somatosensory-motor evoked potentials and placed in the supine position with the appropriate extension of the neck. Perspective positioning, iodophor disinfection, an incision along the transverse cervical line, and the Smith-Robinson approach from the right side reveal the anterior vertebral body. Release of the deep fascia tissue, stripping off the musculus longus colli, localization of the target vertebral. In discectomy or corpectomy according to the preoperative plan, the posterior longitudinal ligament was cut off, and sequential interbody dilation at the same time. The endplate cartilage was curetted until bleeding. Then the appropriate cage or autologous bone was inserted. The correction was made section by section from the kyphosis apex. The titanium plate was pre-bent and fixed to the vertebral body with screws. Then thorough hemostasis, irrigation, placed drainage, and intradermal suture. Those without complications could stand and walk under the head cervical thoracic orthosis(HCTO) on the first day after surgery, the drainage tube was removed with drive traffic < 20 ml/24 h. The HCTO continues to wore 3 months. Observation indicators Clinical efficacy indicators: The visual analogue scale (VAS) score for neck pain and neck disability index (NDI) were conducted at preoperative and last follow-up. Cervical curvature indicators: cervical X-ray in standing position at preoperative, 1 week postoperative, and last follow-up was examined. Cervical spine X-ray or Computed Tomography(CT) was examined in traction state at 1-week post-traction. Measuring cervical curvature parameters. C 2 − 7 Cobb angle: the angle between the parallel line of the lower endplate of C 2 and the parallel line of the lower endplate of C 7 ; Regional kyphosis angle (RKA): the angle between the parallel line of the upper endplate of the upper-end vertebra(UEV) and the parallel line of the lower endplate of the lower end vertebra(LEV); T1 slope (T1S): the angle between the parallel line of the upper endplate of T1 and the horizontal line; C 2 − 7 sagittal vertical axis (C 2 − 7 SVA): the distance between the vertical line through the midpoint of the C 2 vertebra and the posterior superior edge of the C 7 vertebra; Kyphosis index (KI): KI=(A + B + C + D)/E×100, the distance between the posterior superior edge of the UEV and the posterior inferior edge of the LEV is E. The vertical distance from the posterior superior edge of the vertebral body to E of the region of kyphosis was recorded as A, B, C, and D. The above parameters were measured by two doctors, and the average value was taken. Statistical analysis Data were analyzed using the SPSS 25.0 software. All continuous data that meet the normal distribution were presented as mean ± SD (x ± s). The continuous data between different periods were analyzed by t-test. P < 0.05 refers to a significant difference. Results The basic information of the operation All operations were completed in Ⅰ stage. The operation time was 110–210 min, mean 159.82 ± 37.40 min; intraoperative bleeding was 50–110 ml, mean 89.09 ± 19.21 ml. 2 patients with EG accepted anterior cervical corpectomy decompression and fusion(ACCF), the others accepted anterior cervical discectomy and fusion(ACDF). Postoperatively 2 patients had hoarseness, and all of them recovered at discharge from the hospital. The post-laminectomy patients developed distal junctional kyphosis(DJK) at 16 months postoperative(Figure 1 ). None has internal fixation displacement, pseudarthrosis, and adjacent vertebral disease(ASD) at the last follow-up(Table 1 ). Clinical efficacy The VAS score for neck pain and NDI at the last follow-up were smaller than preoperative (p < 0.05)(Table 2 ). Table 2 Comparison of VAS and NDI between preoperative and last follow-up VAS scores NDI scores Preoperative 7.73 ± 0.65 21.18 ± 2.40 Last follow-up 0.82 ± 0.75 3.00 ± 1.84 t 23.126 19.920 p < 0.001 < 0.001 Imaging evaluation C 2 − 7 Cobb angle, RKA, and KI, at post-traction, postoperative and last follow were smaller than preoperative(p < 0.05). C 2 − 7 Cobb angle, RKA, and KI, at postoperative and last follow were smaller than post-traction (p 0.05). C 2 − 7 SVA at post-traction was smaller than in preoperative(p 0.05) (Table 3 ). Table 3 Comparison of imaging measurements of patients at different periods C 2 − 7 Cobb angle(°) RKA(°) KI(%) C 2 − 7 SVA(mm) T1S(°) preoperative 42.00 ± 20.92 57.80 ± 17.19 50.58 ± 18.46 23.03 ± 18.90 12.22 ± 5.90 1-week post-traction 21.11 ± 8.92 35.22 ± 14.65 32.63 ± 15.64 3.43 ± 18.75 14.02 ± 4.65 1-week postoperative -3.32 ± 4.87 6.08 ± 9.30 12.02 ± 3.18 12.88 ± 10.58 14.87 ± 8.09 Last follow-up -4.73 ± 6.51 7.75 ± 7.68 16.09 ± 7.65 13.26 ± 12.74 15.90 ± 8.33 Note : Compared with preoperative, p < 0.05; Compared with 1-week post-traction, p < 0.05 Discussion The lordosis of the cervical depends on the stability of the 3 columns, any one of them disorder can result in cervical kyphosis. EG is the mildest variant of Langerhans cell histiocytosis. They are mostly seen in the pediatric age group and mostly affect the axial skeleton[ 4 ]. In our study, EG damage to the cervical vertebral of 2 patients. Vertebral compression fractures also cause a collapse of vertebrae. Both shorten the anterior and/or middle column resulting in cervical kyphosis. Laminectomy destroys the lamina and posterior cervical musculoligamentous complex, resulting in insufficient resistance to extension. The pathogenesis of idiopathic cervical kyphosis is still unclear, chronic neck flexion postural habit is one of the important risk factors. A case report of a kid who preferred sitting and placing the book on the floor with his head and neck in a flexion position between his thighs to reading progress to cervical kyphosis [ 5 ]. The idiopathic patients in our study also study hard and always do homework with neck flexion to their descriptions. The mechanism is neck flexion postural causes dysfunction of the cervical posterior musculoligamentous complex, resulting in the disability of neck extension [ 6 ]. According to Wolf's law, abnormal stresses interfere with sub-endplate cartilage growth of vertebra after kyphosis occurs, vertebral wedge deformation promotes the progression of kyphosis. Initially, it is soft, the persistent kyphosis leads to contracture of the tissues in the anterior part of the neck and excessive stretching of the tissues in the posterior part of the neck, even heterotopic ossification, gradually progresses to a rigid cervical kyphosis. In addition to non-steroidal anti-inflammatory drugs for pain relief, cervical traction is an effective treatment measure regardless of whether the patient undergoes surgery, especially skull traction. Referring to the study by Wang L et al [ 7 ], all patients underwent skull traction preoperative, and lateral X-rays or CT were performed under skull traction state after 7 days. The results showed significant improvement in cervical kyphosis at post-traction compared to preoperative(p < 0.05). For those primary diseases requiring surgery to cure, C 2 − 7 Cobb angle has more than 8° but less than 40°, unrelieved neck pain, nerve dysfunction, and cervical kyphosis continues to progress, and surgical treatment is recommended. ACF is performed through the natural interstitial approach with less minimal trauma than the posterior-only and combined approach. Patients were discharged from the hospital at 3 to 5 days postoperative in our study. The mainmast symptom of cervical was neck pain, some patients were companied by ventral compression of the spinal cord in the image, but no nerve dysfunction. ACF achieves direct decompression of the spinal cord by removing the disc or the lesion vertebral. In addition, indirect decompression is achieved by decreasing the tone of the posterior cervical muscle and spinal cord after kyphosis is corrected. All patients' symptoms significantly improved at the last follow-up in our study. The VAS score and NDI at the last follow-up were smaller than preoperative (p < 0.05). The principle of orthopedic kyphosis is to increase the height of the anterior column or shorten the height of the posterior column. ACF increases the height of the anterior column by soft tissue release, discectomy, sequential interbody dilation, intervertebral fusion, bending of the plate, and screw lift [ 3 ]. Single-segment ACF can correct 3–5° [ 8 ]. C2-7 cobb angle > 40° was defined as severe kyphosis. ACF for complex, rigid, and severe cervical kyphosis may not be enough, the combined approach should be considered [ 9 ]. In this study, the C2-7 Cobb angle of EG and trauma patients were small than with idiopathic and laminectomy at preoperative, none of the C 2 − 7 Cobb angles was greater than 40° after skull traction. Previous studies have shown that ACF achieved significant orthopedic results in the treatment of degenerative cervical mild or moderate kyphosis in adults [ 10 ]. In our study, The results showed that the patients' C2-7 Cobb angle, RKA, and KI at postoperative and last follow-up are significantly improved compared to the preoperative and post-traction(p < 0.05). TIS is similar to the pelvic incidence angle, Knott et al concluded that T1S increases accompanied by cervical lordosis angle increases [ 11 ], which is similar to the results of the present study. The longer the segment of ACF, the higher the risks. In this study, 2 idiopathic patients who accepted 4ACDF had hoarseness postoperative, both of them had recovered at discharge from the hospital. A previous study aimed at the treatment of multilevel cervical spondylotic myelopathy in adults has shown that the ACF increases the pressure within the adjacent disc, but there is still no clear association with the occurrence of ASD[ 12 ]. Previous studies on the thoracolumbar spine in animals have shown that the implantation of pedicle screws may damage the Neurocentral synchondrosis resulting in delayed vertebral development [ 13 ]. However, studies on AIS patients have shown no adverse effects[ 14 , 15 ]. There is no vertebral growth retardation was observed by the time of the last follow-up in this study. We chose to fuse the segments within the region kyphosis of idiopathic and laminectomy patents(Fig. 1 and Fig. 2 ). For trauma and EG patients(Figure 3 and Fig. 4 ), we nearly fusion the lesioned vertebral. Although the loss of the cervical region of the motor(ROM) remained unavoidable, it did not affect their daily life, similar to the results of Hirvonen et al[ 16 ]. Maybe it is attributed to the high adaptability of adolescents and less than 5 segments. In our study, the laminectomy patient occurred distal junctional kyphosis(DJK) at the last follow-up(Fig. 1 ), but she didn’t have any symptoms. The reasons for DJK may attribute to the disruption of the poster column at first surgery[ 17 ], despite the lamina was pay back. Besides, the plate was too long for her, and the C 6/7 was instability at preoperative but we didn’t fusion to C 7 . If we have chosen a suitable plate and fusion to C 7 at the second surgery, maybe it wouldn't have happened DJK. For blocking the progress of DJK, a combined approach and fusion to the thoracic was performed on the patient again. This article has a few limitations: the study design being retrospective, the small sample size, and the short follow-up period. Conclusion ACF is suited to mild or moderate adolescent cervical kyphosis or can be corrected to mild or moderated by cervical traction. It is effective for improving clinical symptoms with small trauma. For patients with an intact posterior column, ACF is effective for restoring cervical lordosis. For patients without an intact posterior column, ACF-only is not enough, a combined approach should be considered and fused to the thoracic if necessary. Abbreviations ACF anterior cervical fusion ACDF anterior cervical discectomy and fusion ACCF anterior cervical corpectomy and fusion ASD adjacent vertebral disease AIS adolescent idiopathic scoliosis BMI body mass index CT computed tomography C 2-7 SVA C 2-7 sagittal vertical axis DJK distal junctional kyphosis EG eosinophilic granuloma HCTO head cervical thoracic orthosis KI kyphosis index LEV lower end vertebra NDI neck disability index RKA regional kyphosis angle T1S T1 slope UEV upper-end vertebra VAS visual analogue scale Declarations Ethics approval and consent to participate The study was conducted according to the Declaration of Helsinki, and approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Written informed consent was obtained from all of patients and their parents. Consent for publication Not applicable Availability of data and materials The datasets used and analyzed during the current study are not available due to their containing information that could compromise the privacy of research participants but are available from the corresponding. Competing interests There are no competing interests of this article. Funding No funds were received in support of this work. Author Contributions Conception and design: Yahao Tian; data acquisition: Yahao Tian, Kaixu Yu; analysis of data: Yahao Tian; drafting of the manuscript: Yahao Tian; supervision: Feng Li. Acknowledgements Thanks to all individuals who participated in this study. Thanks to the radiology department of TongJi Hospital for supporting me during the follow-up. Author details All authors from department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan Hubei 430030, China. References Virk S, Lafage R, Elysee J, et,al. The 3 Sagittal Morphotypes That Define the Normal Cervical Spine: A Systematic Review of the Literature and an Analysis of Asymptomatic Volunteers. J Bone Joint Surg Am. 2020 Oct 7;102(19):e109. Ailon T, Smith JS, Shaffrey CI, et al. Outcomes of Operative Treatment for Adult Cervical Deformity: A Prospective Multicenter Assessment With 1-Year Follow-up. Neurosurgery. 2018;83(5):1031-1039. Lau D, Ziewacz JE, Le H, et al. A controlled anterior sequential interbody dilation technique for correction of cervical kyphosis. J Neurosurg Spine. 2015;23(3):263-273. Jha SK, De Jesus O. Eosinophilic Granuloma. In: StatPearls . Treasure Island (FL): StatPearls Publishing; January 17, 2022. Wang L, Ibrahim Y, Tian Y, Yuan S, Liu X. Progressive Adolescent Idiopathic Cervical Kyphosis Secondary to Constant Postural Neck Flexion Reading Habit with a 10-year Follow-up: Case Report and Literature Review. Orthop Surg . 2022;14(7):1527-1532. Bonney RA, Corlett EN. Head posture and loading of the cervical spine. Appl Ergon. 2002;33(5):415-417. Wang L, Ibrahim Y, Tian Y, et al. Progressive Adolescent Idiopathic Cervical Kyphosis Secondary to Constant Postural Neck Flexion Reading Habit with a 10-year Follow-up: Case Report and Literature Review. Orthop Surg. 2022;14(7):1527-1532. Gillis CC, Kaszuba MC, Traynelis VC. Cervical radiographic parameters in 1- and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;25(4):421-429. Gadia A, Shah K, Nene A. Cervical Kyphosis. Asian Spine J. 2019;13(1):163-172. Ebot J, Foskey S, Domingo R, et al. Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion. Cureus. 2020;12(6):e8826. Published 2020 Jun 25. Knott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10(11):994-998. Xu S, Liang Y, Yu G, Zhu Z, Wang K, Liu H. Exploration on sagittal alignment and clinical outcomes after consecutive three-level hybrid surgery and anterior cervical discectomy and fusion: a minimum of a 5-year follow-up. J Orthop Surg Res . 2020;15(1):79. Published 2020 Feb 26. Cil A, Yazici M, Daglioglu K, et al. The effect of pedicle screw placement with or without application of compression across the neurocentral cartilage on the morphology of the spinal canal and pedicle in immature pigs. Spine (Phila Pa 1976). 2005 Jun 1;30(11):1287-93. Ruf M, Harms J. Pedicle screws in 1- and 2-year-old children: technique, complications, and effect on further growth. Spine (Phila Pa 1976). 2002 Nov 1;27(21):E460-6. Li J, Lü GH, Wang B, et al. Pedicle screw implantation in the thoracic and lumbar spine of 1-4-year-old children: evaluating the safety and accuracy by a computer tomography follow-up. J Spinal Disord Tech. 2013 Apr;26(2): E46-52. Hirvonen T, Marjamaa J, Siironen J, et al. Young adults undergoing ACDF surgery exhibit decreased health-related quality of life in the long term in comparison to the general population. Spine J. 2021;21(6):924-936. Passias PG, Horn SR, Oh C, et al. Predicting the Occurrence of Postoperative Distal Junctional Kyphosis in Cervical Deformity Patients. Neurosurgery . 2020;86(1):E38-E46. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2144854","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":145754659,"identity":"bec8239d-5fed-41f8-b28e-8306fa4686b3","order_by":0,"name":"Yahao Tian","email":"","orcid":"","institution":"Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yahao","middleName":"","lastName":"Tian","suffix":""},{"id":145754660,"identity":"fa777045-128d-419a-acc5-493eac7dd7b1","order_by":1,"name":"Kaixu 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Technology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2022-10-08 10:14:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2144854/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2144854/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28186434,"identity":"7e20645f-287e-46c4-a3ca-be602d2cc2b3","added_by":"auto","created_at":"2022-10-24 16:10:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":344702,"visible":true,"origin":"","legend":"\u003cp\u003eAn 11-year-old female patient underwent laminectomy and the lamina was paid back 6 months ago. \u003cstrong\u003ea\u003c/strong\u003e Preoperative lateral X-ray indicated cervical kyphosis, wedging of the vertebral body. \u003cstrong\u003eb\u003c/strong\u003e post-traction lateral X-ray at 1 week indicated cervical kyphosis is partially corrected.\u003cstrong\u003e c\u003c/strong\u003epostoperative lateral X-ray at 1 week indicated the patient accepted 3-segment ACDF with long plate and cervical curvature returned to lordosis.\u003cstrong\u003e d-f \u003c/strong\u003epostoperative lateral X-ray, CT, and MRI at 16 months indicated the cervical lordosis was partially lost and DJK has occurred with mild spinal cord compression. \u003cstrong\u003eg-h\u003c/strong\u003eremoval of internal fixation, a combined approach, and fused to T1 were performed on the patient.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2144854/v1/1d5bff72733d8659d982513f.png"},{"id":28186937,"identity":"3a1bd4fd-0dd2-4c6c-a344-ae0d16f415f3","added_by":"auto","created_at":"2022-10-24 16:15:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":137937,"visible":true,"origin":"","legend":"\u003cp\u003eA 13-year-old male patient with AICK. \u003cstrong\u003ea\u003c/strong\u003e Preoperative lateral X-ray indicated cervical kyphosis, wedging of the vertebral body. \u003cstrong\u003eb\u003c/strong\u003e post-traction lateral X-ray at 1 week indicated cervical kyphosis is partially corrected. \u003cstrong\u003ec\u003c/strong\u003e postoperative lateral X-ray at 1 week indicated the patient accepted 4-segment ACDF with long plate and cervical curvature returned to lordosis. \u003cstrong\u003ed\u003c/strong\u003e postoperative lateral X-ray at 23 months indicated lordosis was well maintained and bony fusion has been obtained.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2144854/v1/a7dbee173e11b0f126eca58d.png"},{"id":28186437,"identity":"61631947-3c08-41de-87ef-f0b5da68c334","added_by":"auto","created_at":"2022-10-24 16:10:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":301883,"visible":true,"origin":"","legend":"\u003cp\u003eA 15-year-old male patient with trauma 9 months ago. \u003cstrong\u003ea\u003c/strong\u003e Preoperative lateral X-ray indicated cervical kyphosis, wedging of the vertebral body. \u003cstrong\u003eb \u003c/strong\u003epost-traction CT at 1 week indicated C4 and C5 old compression fractures. \u003cstrong\u003ec\u003c/strong\u003e postoperative lateral X-ray at 1 week indicated the patient accepted 2-segment ACDF with plate and cervical curvature returned to lordosis.\u003cstrong\u003ed\u003c/strong\u003e postoperative lateral X-ray at 12 months indicated the cervical lordosis was well maintained and bony fusion has been obtained.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2144854/v1/6812c684a3ed2286a5c7c56b.png"},{"id":28186436,"identity":"bec4f67a-7b22-4f23-a52b-7c3c3eb08d06","added_by":"auto","created_at":"2022-10-24 16:10:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":204251,"visible":true,"origin":"","legend":"\u003cp\u003eA 10-year-old female patient with EG. \u003cstrong\u003ea\u003c/strong\u003e Preoperative lateral X-ray indicated cervical kyphosis, compression of the C6 vertebral body. \u003cstrong\u003eb \u003c/strong\u003epost-traction lateral X-ray at 1 week indicated cervical kyphosis is partially corrected. \u003cstrong\u003ec\u003c/strong\u003epostoperative lateral X-ray at 1 week indicated the patient accepted C6 \u003cem\u003ecorpectomy and fusion \u003c/em\u003ewith autologous iliac bone graft, cervical curvature returned significantly corrected. \u003cstrong\u003ed\u003c/strong\u003e postoperative lateral X-ray at 14 months indicated the cervical lordosis was well maintained and bony fusion has been obtained.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2144854/v1/5c728e52df6864e3ffd84f50.png"},{"id":28455944,"identity":"8bf57235-4429-42be-be72-f0ec3fa6b7c2","added_by":"auto","created_at":"2022-10-31 13:29:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1220375,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2144854/v1/b71a483a-dd19-46fc-9e31-b41e84dd53be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy analysis of anterior cervical fusion in the treatment of adolescent cervical kyphosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is no clear definition of cervical kyphosis, and previous studies have defined it with a C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle\u0026thinsp;\u0026ge;\u0026thinsp;8\u0026deg; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Etiology of cervical kyphosis includes tumor, trauma, idiopathic, medical origin and infection, etc. Clinical symptoms of cervical kyphosis include neck pain, neck kyphosis, numbness or pain in the limbs, limited flat vision, dyspnea, dysphagia, and disability[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCervical traction and external fixation brace are commonly used for conservative treatment. For those who fail conservative treatment, surgical treatment remains a challenge in spinal surgery due to adolescent still growth and development. Posterior-only approach or the combined approach is highly invasive and disrupts the posterior column. Previous studies have confirmed that anterior cervical fusion (ACF) can achieve spinal decompression and cervical curvature correction with small trauma and beautiful incision[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Fewer studies have previously reported on ACF for adolescent cervical kyphosis, this study aims to evaluate the safety and effectiveness of this procedure.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003e Inclusion criteria: Age\u0026thinsp;\u0026le;\u0026thinsp;18 years; Neck pain, neurological dysfunction, progression of kyphosis, and ineffective conservative treatment more than 3 months; Accepted ACF treatment at our hospital and the surgery was performed by the same team. Complete medical records and imaging data.\u003c/p\u003e \u003cp\u003eexclusion criteria: Adolescent idiopathic scoliosis(AIS); Ankylosing spondylitis; Motor neuron disease; Thoracic or lumbar spine disease.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eA total of 11 patients were included and followed up for more than 1 year. 6 with idiopathic, 1 with laminectomy, 2 with eosinophilic granuloma(EG), and 2 with trauma. Age 14.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62 years; Body Mass Index (BMI) 18.14\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18 kg/m\u003csup\u003e2\u003c/sup\u003e; Course of disease 13.91\u0026thinsp;\u0026plusmn;\u0026thinsp;14.59 months; Follow-up 42.45\u0026thinsp;\u0026plusmn;\u0026thinsp;36.68 months. All patients received skull traction, mean of 9.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 days, gradually increasing the traction weight to no more than 1/4 of their body weight (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe general information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003epatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e(M/F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003epathogenesis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003cp\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eACF manners\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTraction time(days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ecomplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ehoarseness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ehoarseness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003elaminectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDJK\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eACCF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eACCF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgery procedure\u003c/h2\u003e \u003cp\u003eAll operations were performed by the same group. Under general anesthesia, the patient was connected to somatosensory-motor evoked potentials and placed in the supine position with the appropriate extension of the neck. Perspective positioning, iodophor disinfection, an incision along the transverse cervical line, and the Smith-Robinson approach from the right side reveal the anterior vertebral body. Release of the deep fascia tissue, stripping off the musculus longus colli, localization of the target vertebral. In discectomy or corpectomy according to the preoperative plan, the posterior longitudinal ligament was cut off, and sequential interbody dilation at the same time. The endplate cartilage was curetted until bleeding. Then the appropriate cage or autologous bone was inserted. The correction was made section by section from the kyphosis apex. The titanium plate was pre-bent and fixed to the vertebral body with screws. Then thorough hemostasis, irrigation, placed drainage, and intradermal suture. Those without complications could stand and walk under the head cervical thoracic orthosis(HCTO) on the first day after surgery, the drainage tube was removed with drive traffic\u0026thinsp;\u0026lt;\u0026thinsp;20 ml/24 h. The HCTO continues to wore 3 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eObservation indicators\u003c/h2\u003e \u003cp\u003eClinical efficacy indicators: The visual analogue scale (VAS) score for neck pain and neck disability index (NDI) were conducted at preoperative and last follow-up.\u003c/p\u003e \u003cp\u003eCervical curvature indicators: cervical X-ray in standing position at preoperative, 1 week postoperative, and last follow-up was examined. Cervical spine X-ray or Computed Tomography(CT) was examined in traction state at 1-week post-traction. Measuring cervical curvature parameters. C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle: the angle between the parallel line of the lower endplate of C\u003csub\u003e2\u003c/sub\u003e and the parallel line of the lower endplate of C\u003csub\u003e7\u003c/sub\u003e; Regional kyphosis angle (RKA): the angle between the parallel line of the upper endplate of the upper-end vertebra(UEV) and the parallel line of the lower endplate of the lower end vertebra(LEV); T1 slope (T1S): the angle between the parallel line of the upper endplate of T1 and the horizontal line; C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e sagittal vertical axis (C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e SVA): the distance between the vertical line through the midpoint of the C\u003csub\u003e2\u003c/sub\u003e vertebra and the posterior superior edge of the C\u003csub\u003e7\u003c/sub\u003e vertebra; Kyphosis index (KI): KI=(A\u0026thinsp;+\u0026thinsp;B\u0026thinsp;+\u0026thinsp;C\u0026thinsp;+\u0026thinsp;D)/E\u0026times;100, the distance between the posterior superior edge of the UEV and the posterior inferior edge of the LEV is E. The vertical distance from the posterior superior edge of the vertebral body to E of the region of kyphosis was recorded as A, B, C, and D. The above parameters were measured by two doctors, and the average value was taken.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using the SPSS 25.0 software. All continuous data that meet the normal distribution were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s). The continuous data between different periods were analyzed by t-test. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 refers to a significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eThe basic information of the operation\u003c/h2\u003e \u003cp\u003eAll operations were completed in Ⅰ stage. The operation time was 110\u0026ndash;210 min, mean 159.82\u0026thinsp;\u0026plusmn;\u0026thinsp;37.40 min; intraoperative bleeding was 50\u0026ndash;110 ml, mean 89.09\u0026thinsp;\u0026plusmn;\u0026thinsp;19.21 ml. 2 patients with EG accepted anterior cervical corpectomy decompression and fusion(ACCF), the others accepted anterior cervical discectomy and fusion(ACDF). Postoperatively 2 patients had hoarseness, and all of them recovered at discharge from the hospital. The post-laminectomy patients developed distal junctional kyphosis(DJK) at 16 months postoperative(Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). None has internal fixation displacement, pseudarthrosis, and adjacent vertebral disease(ASD) at the last follow-up(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eClinical efficacy\u003c/h2\u003e \u003cp\u003eThe VAS score for neck pain and NDI at the last follow-up were smaller than preoperative (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of VAS and NDI between preoperative and last follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVAS scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNDI scores\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImaging evaluation\u003c/h2\u003e \u003cp\u003eC\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle, RKA, and KI, at post-traction, postoperative and last follow were smaller than preoperative(p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle, RKA, and KI, at postoperative and last follow were smaller than post-traction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle, RKA, and KI, at the last follow-up, were greater than postoperative(p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e SVA at post-traction was smaller than in preoperative(p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The difference in the change of T1S during the treatment was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of imaging measurements of patients at different periods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle(\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRKA(\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKI(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e SVA(mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT1S(\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.00\u0026thinsp;\u0026plusmn;\u0026thinsp;20.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e57.80\u0026thinsp;\u0026plusmn;\u0026thinsp;17.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e50.58\u0026thinsp;\u0026plusmn;\u0026thinsp;18.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e23.03\u0026thinsp;\u0026plusmn;\u0026thinsp;18.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e12.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-week post-traction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.11\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e35.22\u0026thinsp;\u0026plusmn;\u0026thinsp;14.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.63\u0026thinsp;\u0026plusmn;\u0026thinsp;15.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;18.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e14.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-week postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-3.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.08\u0026thinsp;\u0026plusmn;\u0026thinsp;9.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e12.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e12.88\u0026thinsp;\u0026plusmn;\u0026thinsp;10.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e14.87\u0026thinsp;\u0026plusmn;\u0026thinsp;8.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.75\u0026thinsp;\u0026plusmn;\u0026thinsp;7.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.09\u0026thinsp;\u0026plusmn;\u0026thinsp;7.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e13.26\u0026thinsp;\u0026plusmn;\u0026thinsp;12.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e15.90\u0026thinsp;\u0026plusmn;\u0026thinsp;8.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote\u003c/b\u003e: Compared with preoperative, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Compared with 1-week post-traction, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe lordosis of the cervical depends on the stability of the 3 columns, any one of them disorder can result in cervical kyphosis. EG is the mildest variant of Langerhans cell histiocytosis. They are mostly seen in the pediatric age group and mostly affect the axial skeleton[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In our study, EG damage to the cervical vertebral of 2 patients. Vertebral compression fractures also cause a collapse of vertebrae. Both shorten the anterior and/or middle column resulting in cervical kyphosis. Laminectomy destroys the lamina and posterior cervical musculoligamentous complex, resulting in insufficient resistance to extension. The pathogenesis of idiopathic cervical kyphosis is still unclear, chronic neck flexion postural habit is one of the important risk factors. A case report of a kid who preferred sitting and placing the book on the floor with his head and neck in a flexion position between his thighs to reading progress to cervical kyphosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The idiopathic patients in our study also study hard and always do homework with neck flexion to their descriptions. The mechanism is neck flexion postural causes dysfunction of the cervical posterior musculoligamentous complex, resulting in the disability of neck extension [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to Wolf's law, abnormal stresses interfere with sub-endplate cartilage growth of vertebra after kyphosis occurs, vertebral wedge deformation promotes the progression of kyphosis. Initially, it is soft, the persistent kyphosis leads to contracture of the tissues in the anterior part of the neck and excessive stretching of the tissues in the posterior part of the neck, even heterotopic ossification, gradually progresses to a rigid cervical kyphosis.\u003c/p\u003e \u003cp\u003eIn addition to non-steroidal anti-inflammatory drugs for pain relief, cervical traction is an effective treatment measure regardless of whether the patient undergoes surgery, especially skull traction. Referring to the study by Wang L et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], all patients underwent skull traction preoperative, and lateral X-rays or CT were performed under skull traction state after 7 days. The results showed significant improvement in cervical kyphosis at post-traction compared to preoperative(p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For those primary diseases requiring surgery to cure, C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angle has more than 8\u0026deg; but less than 40\u0026deg;, unrelieved neck pain, nerve dysfunction, and cervical kyphosis continues to progress, and surgical treatment is recommended.\u003c/p\u003e \u003cp\u003eACF is performed through the natural interstitial approach with less minimal trauma than the posterior-only and combined approach. Patients were discharged from the hospital at 3 to 5 days postoperative in our study. The mainmast symptom of cervical was neck pain, some patients were companied by ventral compression of the spinal cord in the image, but no nerve dysfunction. ACF achieves direct decompression of the spinal cord by removing the disc or the lesion vertebral. In addition, indirect decompression is achieved by decreasing the tone of the posterior cervical muscle and spinal cord after kyphosis is corrected. All patients' symptoms significantly improved at the last follow-up in our study. The VAS score and NDI at the last follow-up were smaller than preoperative (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The principle of orthopedic kyphosis is to increase the height of the anterior column or shorten the height of the posterior column. ACF increases the height of the anterior column by soft tissue release, discectomy, sequential interbody dilation, intervertebral fusion, bending of the plate, and screw lift [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Single-segment ACF can correct 3\u0026ndash;5\u0026deg; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. C2-7 cobb angle\u0026thinsp;\u0026gt;\u0026thinsp;40\u0026deg; was defined as severe kyphosis. ACF for complex, rigid, and severe cervical kyphosis may not be enough, the combined approach should be considered [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, the C2-7 Cobb angle of EG and trauma patients were small than with idiopathic and laminectomy at preoperative, none of the C\u003csub\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/sub\u003e Cobb angles was greater than 40\u0026deg; after skull traction. Previous studies have shown that ACF achieved significant orthopedic results in the treatment of degenerative cervical mild or moderate kyphosis in adults [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, The results showed that the patients' C2-7 Cobb angle, RKA, and KI at postoperative and last follow-up are significantly improved compared to the preoperative and post-traction(p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). TIS is similar to the pelvic incidence angle, Knott et al concluded that T1S increases accompanied by cervical lordosis angle increases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which is similar to the results of the present study.\u003c/p\u003e \u003cp\u003eThe longer the segment of ACF, the higher the risks. In this study, 2 idiopathic patients who accepted 4ACDF had hoarseness postoperative, both of them had recovered at discharge from the hospital. A previous study aimed at the treatment of multilevel cervical spondylotic myelopathy in adults has shown that the ACF increases the pressure within the adjacent disc, but there is still no clear association with the occurrence of ASD[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previous studies on the thoracolumbar spine in animals have shown that the implantation of pedicle screws may damage the Neurocentral synchondrosis resulting in delayed vertebral development [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, studies on AIS patients have shown no adverse effects[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. There is no vertebral growth retardation was observed by the time of the last follow-up in this study. We chose to fuse the segments within the region kyphosis of idiopathic and laminectomy patents(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For trauma and EG patients(Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), we nearly fusion the lesioned vertebral. Although the loss of the cervical region of the motor(ROM) remained unavoidable, it did not affect their daily life, similar to the results of Hirvonen et al[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Maybe it is attributed to the high adaptability of adolescents and less than 5 segments. In our study, the laminectomy patient occurred distal junctional kyphosis(DJK) at the last follow-up(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), but she didn\u0026rsquo;t have any symptoms. The reasons for DJK may attribute to the disruption of the poster column at first surgery[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], despite the lamina was pay back. Besides, the plate was too long for her, and the C\u003csub\u003e6/7\u003c/sub\u003e was instability at preoperative but we didn\u0026rsquo;t fusion to C\u003csub\u003e7\u003c/sub\u003e. If we have chosen a suitable plate and fusion to C\u003csub\u003e7\u003c/sub\u003e at the second surgery, maybe it wouldn't have happened DJK. For blocking the progress of DJK, a combined approach and fusion to the thoracic was performed on the patient again. This article has a few limitations: the study design being retrospective, the small sample size, and the short follow-up period.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eACF is suited to mild or moderate adolescent cervical kyphosis or can be corrected to mild or moderated by cervical traction. It is effective for improving clinical symptoms with small trauma. For patients with an intact posterior column, ACF is effective for restoring cervical lordosis. For patients without an intact posterior column, ACF-only is not enough, a combined approach should be considered and fused to the thoracic if necessary.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eACF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eanterior cervical fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eACDF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eanterior cervical discectomy and fusion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eACCF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eanterior cervical corpectomy and fusion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eadjacent vertebral disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eadolescent idiopathic scoliosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003e\u003cem\u003ebody mass index\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003ecomputed tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eC\u003csub\u003e2-7\u003c/sub\u003e SVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eC\u003csub\u003e2-7\u003c/sub\u003e sagittal vertical axis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eDJK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003edistal junctional kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eeosinophilic granuloma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eHCTO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003ehead cervical thoracic orthosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003ekyphosis index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eLEV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003elower end vertebra\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eNDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eneck disability index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eRKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eregional kyphosis angle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eT1S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eT1 slope\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eUEV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003eupper-end vertebra\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"24.115755627009648%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.88424437299035%\"\u003e\n \u003cp\u003evisual analogue scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the Declaration of Helsinki, and approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Written informed consent was obtained from all of patients and their parents. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are not available due to their containing information that could compromise the privacy of research participants but are available from the corresponding.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no competing interests of this article.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds were received in support of this work.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design:\u0026nbsp;Yahao Tian; data acquisition:\u0026nbsp;Yahao Tian, Kaixu Yu; analysis of data:\u0026nbsp;Yahao Tian; drafting of the manuscript:\u0026nbsp;Yahao Tian; supervision:\u0026nbsp;Feng Li.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to all individuals who participated in this study. Thanks to the radiology department of TongJi Hospital for supporting me during the follow-up.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors from department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan Hubei 430030, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVirk S, Lafage R, Elysee J, et,al. The 3 Sagittal Morphotypes That Define the Normal Cervical Spine: A Systematic Review of the Literature and an Analysis of Asymptomatic Volunteers. J Bone Joint Surg Am. 2020 Oct 7;102(19):e109.\u003c/li\u003e\n\u003cli\u003eAilon T, Smith JS, Shaffrey CI, et al. Outcomes of Operative Treatment for Adult Cervical Deformity: A Prospective Multicenter Assessment With 1-Year Follow-up. Neurosurgery. 2018;83(5):1031-1039. \u003c/li\u003e\n\u003cli\u003eLau D, Ziewacz JE, Le H, et al. A controlled anterior sequential interbody dilation technique for correction of cervical kyphosis. J Neurosurg Spine. 2015;23(3):263-273.\u003c/li\u003e\n\u003cli\u003eJha SK, De Jesus O. Eosinophilic Granuloma. In: \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL): StatPearls Publishing; January 17, 2022.\u003c/li\u003e\n\u003cli\u003eWang L, Ibrahim Y, Tian Y, Yuan S, Liu X. Progressive Adolescent Idiopathic Cervical Kyphosis Secondary to Constant Postural Neck Flexion Reading Habit with a 10-year Follow-up: Case Report and Literature Review. \u003cem\u003eOrthop Surg\u003c/em\u003e. 2022;14(7):1527-1532. \u003c/li\u003e\n\u003cli\u003eBonney RA, Corlett EN. Head posture and loading of the cervical spine. Appl Ergon. 2002;33(5):415-417. \u003c/li\u003e\n\u003cli\u003eWang L, Ibrahim Y, Tian Y, et al. Progressive Adolescent Idiopathic Cervical Kyphosis Secondary to Constant Postural Neck Flexion Reading Habit with a 10-year Follow-up: Case Report and Literature Review. Orthop Surg. 2022;14(7):1527-1532.\u003c/li\u003e\n\u003cli\u003eGillis CC, Kaszuba MC, Traynelis VC. Cervical radiographic parameters in 1- and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;25(4):421-429.\u003c/li\u003e\n\u003cli\u003eGadia A, Shah K, Nene A. Cervical Kyphosis. Asian Spine J. 2019;13(1):163-172. \u003c/li\u003e\n\u003cli\u003eEbot J, Foskey S, Domingo R, et al. Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion. Cureus. 2020;12(6):e8826. Published 2020 Jun 25.\u003c/li\u003e\n\u003cli\u003eKnott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10(11):994-998. \u003c/li\u003e\n\u003cli\u003eXu S, Liang Y, Yu G, Zhu Z, Wang K, Liu H. Exploration on sagittal alignment and clinical outcomes after consecutive three-level hybrid surgery and anterior cervical discectomy and fusion: a minimum of a 5-year follow-up. \u003cem\u003eJ Orthop Surg Res\u003c/em\u003e. 2020;15(1):79. Published 2020 Feb 26. \u003c/li\u003e\n\u003cli\u003eCil A, Yazici M, Daglioglu K, et al. The effect of pedicle screw placement with or without application of compression across the neurocentral cartilage on the morphology of the spinal canal and pedicle in immature pigs. Spine (Phila Pa 1976). 2005 Jun 1;30(11):1287-93. \u003c/li\u003e\n\u003cli\u003eRuf M, Harms J. Pedicle screws in 1- and 2-year-old children: technique, complications, and effect on further growth. Spine (Phila Pa 1976). 2002 Nov 1;27(21):E460-6. \u003c/li\u003e\n\u003cli\u003eLi J, L\u0026uuml; GH, Wang B, et al. Pedicle screw implantation in the thoracic and lumbar spine of 1-4-year-old children: evaluating the safety and accuracy by a computer tomography follow-up. J Spinal Disord Tech. 2013 Apr;26(2): E46-52.\u003c/li\u003e\n\u003cli\u003eHirvonen T, Marjamaa J, Siironen J, et al. Young adults undergoing ACDF surgery exhibit decreased health-related quality of life in the long term in comparison to the general population. Spine J. 2021;21(6):924-936.\u003c/li\u003e\n\u003cli\u003ePassias PG, Horn SR, Oh C, et al. Predicting the Occurrence of Postoperative Distal Junctional Kyphosis in Cervical Deformity Patients. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2020;86(1):E38-E46.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, cervical kyphosis, anterior cervical fusion, laminectomy, skull traction, distal junctional kyphosis","lastPublishedDoi":"10.21203/rs.3.rs-2144854/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2144854/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Surgical treatment remains a challenge for the treatment of adolescent cervical kyphosis, anterior cervical fusion (ACF) can correct kyphosis with small trauma. To study the efficacy and application scope of ACF for the treatment of adolescent cervical kyphosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Patients younger than 18 years old who had undergone anterior cervical discectomy/corpectomy and fusion (ACDF/ACCF) for cervical kyphosis from 2013.1 to 2020.12 in our hospital were retrospectively analyzed. The visual analogue scale (VAS) score for neck pain and neck disability index (NDI) were recorded at preoperative and the last follow-up. The C\u003csub\u003e2-7\u003c/sub\u003e Cobb angle, regional kyphosis angle (RKA), kyphosis index (KI), T1 slope (T1S), and C\u003csub\u003e2-7\u003c/sub\u003e sagittal vertical axis (C\u003csub\u003e2-7\u003c/sub\u003e SVA) were measured at preoperative, 1-week post-traction, 1-week postoperative, and last follow-up. Data were analyzed using the SPSS 25.0 software and p \u0026lt; 0.05 refers to a significant difference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eA total of 11 patients were included, 6 with idiopathic, 1 with laminectomy, 2 with eosinophilic granuloma(EG), and 2 with trauma. All accepted skull-traction, the cervical kyphosis angle shows significant improvement at post-traction than preoperative. 9 patients accepted anterior cervical discectomy and fusion(ACDF), and 2 patients accepted \u003cem\u003eanterior cervical corpectomy decompression and fusion\u003c/em\u003e(ACCF). The laminectomy patient occurred distal junctional kyphosis(DJK) at the last follow-up. The VAS score of neck pain and NDI at the last follow-up were smaller than preoperative (p\u0026lt;0.05). The cervical kyphosis angle shows significant improvement at postoperative and the last follow-up than preoperative and post-traction. There is no significant difference in cervical curvature between the postoperative and last follow-up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e ACF is suited to mild or moderate adolescent cervical kyphosis or can be corrected to mild or moderated by cervical traction. It is effective for improving clinical symptoms with small trauma. For patients with an intact posterior column, ACF is effective for restoring cervical lordosis. For patients without an intact posterior column, ACF-only is not enough, a combined approach should be considered and fused to the thoracic if necessary.\u003c/p\u003e","manuscriptTitle":"Efficacy analysis of anterior cervical fusion in the treatment of adolescent cervical kyphosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-24 16:10:42","doi":"10.21203/rs.3.rs-2144854/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"de52e534-456a-402a-9e3c-7ecc26953e1e","owner":[],"postedDate":"October 24th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-31T13:29:29+00:00","versionOfRecord":[],"versionCreatedAt":"2022-10-24 16:10:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2144854","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2144854","identity":"rs-2144854","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}