Is Fixation Procedure Necessary in Posterior Approach Surgery for Cervical Stenosis with Non-Severe Kyphosis?

Is Fixation Procedure Necessary in Posterior Approach Surgery for Cervical Stenosis with Non-Severe 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 Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Is Fixation Procedure Necessary in Posterior Approach Surgery for Cervical Stenosis with Non-Severe Kyphosis? Hongyu Chen, Xiaoxiong Yang, Pinhan Wu, Shengfa Pan, Yanbin Zhao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7292535/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 Objectives To evaluate whether the fixation procedure is essential in posterior surgery for cervical stenosis with non-severe kyphosis. Methods A total of 109 patients diagnosed with cervical stenosis and non-severe kyphosis were included in this study. Patients were categorized based on the surgical approach into those who underwent laminoplasty (LP) alone and those who received fixation with either lateral mass screws (LMS) or pedicle screws (PS). Preoperative and postoperative assessments included the Visual Analog Scale (VAS) for neck pain, the modified Japanese Orthopaedic Association (mJOA) score, the Neck Disability Index (NDI), and the Short Form 36 (SF36) health survey. Sagittal parameters were measured using lateral cervical radiographs. Additionally, hospitalization data, surgical details, and complications were collected. Results No significant differences were observed in baseline demographic characteristics among the three groups. However, the PS group had significantly longer operative duration and greater intraoperative blood loss compared to the others groups. Postoperative mJOA scores improved significantly in all groups. However, the PS group had significantly lower follow-up mJOA scores (12.8 ± 2.9) compared to the LP (15.4 ± 1.7, P < 0.001) and LMS groups (15.6 ± 1.5, P = 0.002). VAS scores demonstrated significant pain reduction in the PS group (preoperative 3.8 ± 2.2 vs. follow-up 2.6 ± 1.8, P = 0.046), whereas changes in the LP (-0.2 ± 2.8, P = 0.877) and LMS groups (-0.3 ± 2.7, P = 0.877) were minimal. The PS group achieved the most pronounced correction in C2-7 Cobb angle (8.6 ± 11.7°) during surgeries. The LMS group did not achieve significant kyphosis correction, with a postoperative improvement in C2-7 Cobb angle of only 3.4 ± 7.7°, comparable to the LP group (3.8 ± 7.8°, P = 0.840). The overall complication rate was highest in the PS group (27.8%), followed by the LMS group (16.0%) and the LP group (9.1%). Conclusion This study suggests that fixation may not be essential in posterior surgery for cervical stenosis with non-severe kyphosis. Posterior surgeries without fixation were associated with shorter operative times, reduced blood loss, comparable neurological recovery and quality of life outcomes to those with fixation, as well as a lower incidence of postoperative complications. cervical kyphosis laminoplasty posterior decompression fixation Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Multilevel cervical spondylotic myelopathy (CSM) induces neurological deficits through spinal cord compression 1 . Degenerative changes in the facet joints and intervertebral discs may lead to sagittal imbalance, contributing to cervical kyphosis 2 . To halt functional deterioration, surgical intervention is frequently considered. Some scholars 3 – 5 regarded preoperative cervical kyphosis as a relative contraindication for standalone posterior decompression due to the reduced posterior shift of the spinal cord, which could interfere with indirect anterior decompression. However, some studies have shown that standalone posterior decompression does not necessarily result in inferior neurological outcomes. Uchida et al. 6 compared the surgical outcomes of anterior decompression and fusion versus laminoplasty (LP) in patients with cervical kyphosis. They found that although patients undergoing laminoplasty alone still had cervical kyphosis, both groups exhibited comparable neurological improvement. Similarly, Nagoshi et al. 7 reported that patients with mild cervical kyphosis who underwent laminoplasty also achieved favorable clinical outcomes. These findings suggest that there is no consensus on the optimal treatment for patients with CSM and preoperative cervical kyphosis. Posterior decompression combined with screw fixation represents a classical surgical strategy for multilevel cervical stenosis with kyphosis. Fixation techniques include lateral mass screws (LMS) and pedicle screws (PS). The use of LMS in posterior cervical fixation and stabilization has become increasingly common 8 . When correcting cervical kyphosis with LMS, anterior fusion may also be required 9 . From a biomechanical perspective, PS provide greater stability than LMS, offering higher pullout strength and can be used for kyphosis correction 10 . However, their widespread application is limited by a steeper learning curve and the potential risk of catastrophic complications, such as arterial injury 11 – 13 . For cases of non-severe cervical kyphosis, the purported advantages of PS fixation, such as higher pullout strength and greater resistance to fixation failure, may not be clinically relevant. This study aims to clarify whether fixation procedure is necessary for patients with degenerative cervical spinal stenosis and non-severe kyphotic deformity by comparing clinical and radiological outcomes between those who underwent posterior surgery with and without fixation. To differentiate screw types, we categorize the fixation group into those using LMS and those using PS for comparison. Methods 1, Patient characteristics This retrospective study was approved by the institutional review board of our institute (number: M2022752). Patients diagnosed with multi-level cervical spinal canal stenosis and degenerative cervical kyphosis who underwent posterior surgery at our institution between January 2013 and January 2024 were retrospectively reviewed. The inclusion criteria were as follows: (1) aged between 18 and 75 years; (2) marked degenerative cervical kyphosis through cervical standing lateral plain films (C2-7 Cobb angle 10°); (3) complete clinical and radiological imaging data. The exclusion criteria were as follows: (1) combinations with anterior surgery; (2) severe kyphosis (C2-7 Cobb angle < -25°) (3) with cervical deformities such as scoliosis, atlantoaxial dislocation, basilar invagination, atlanto-occipital fusion, cervical segmentation defects, or spina bifida; (4) pathologies requiring differential management (tumors, fractures, infections or congenital cervical kyphosis); (5) prior cervical spine surgery; (6) comorbidities affecting neurological assessments (intracranial lesions, intramedullary pathologies, myasthenia gravis, intellectual disability, or neuropsychiatric disorders). 2, Operative technique Patients were stratified into three groups based on surgical approach: laminoplasty alone (LP), laminoplasty with lateral mass screw fixation (hereinafter referred to as LMS), and laminoplasty with pedicle screw fixation (hereinafter referred to as PS). All surgical procedures across the three groups were performed by the same team of experienced spine surgeons and with standardized preoperative planning. After securing the head in a Mayfield three-pin fixation device, the patient was positioned prone. A midline incision exposed the posterior cervical elements. In the LP group (Fig. 1 ), surgical procedures were performed as follows: On the right side, a trough was created at the lamina-facet junction by removing the outer cortical bone to serve as the hinge, while a complete osteotomy through both the inner and outer cortical layers was performed at the lamina-facet junction on the left side. The laminar door was then elevated and secured in the expanded position using titanium miniplates or titanium cables. Throughout the procedure, meticulous care was taken to preserve the bilateral deep extensor musculature and ligamentous structures. In the LMS group (Fig. 2 ), the procedure involved lateral mass screw placement and LP. Lateral mass screw were placed bilaterally using the Magerl technique 14 . Appropriately sized rods were selected, contoured to match the physiological cervical lordosis, and secured to the lateral masses with screws. LP was then performed according to the preoperative surgical plan. In the PS group (Fig. 3 ), polyaxial titanium pedicle screws were inserted into the pedicles of the targeted fusion segments. Fluoroscopy was utilized to confirm optimal screw trajectory and depth. Titanium rods of appropriate length were contoured to an adequate curvature to restore cervical lordotic curvature and subsequently connected to the screw heads. During rod-screw fixation, a distraction-compression maneuver was applied to cranial and caudal screws to facilitate reduction, while manual ventral pressure was exerted on the mid-level spinous processes and laminae to assist kyphosis correction. LP was then performed following the standardized protocol. 3, Clinical evaluation Patient demographics, surgical characteristics, preoperative baseline and follow-up clinical data were collected. Modified Japanese Orthopedic Association (mJOA) score, Visual Analog Scale (VAS) for neck pain, Neck Disability Index (NDI), and the Short Form 36 (SF36) health survey were recorded before surgery and at follow-up. The neurological recovery rate was calculated using the following formula: (postoperative JOA score - preoperative score)/(17 - preoperative score)×100%. Improvement in neck pain was assessed by calculating the difference between postoperative and preoperative VAS scores (postoperative VAS - preoperative VAS). 4, Radiographic assessment Preoperative, postoperative and follow-up radiographic assessment were carried out by 2 independent observers whose results were averaged. The intraobserver errors were less than 5%. The C2-7 Cobb angle was measured on standing lateral radiographs as the angle formed by the intersection of lines drawn along the inferior endplates of C2 and C7, with positive values indicating lordosis and negative values indicating kyphosis. The cervical range of motion (ROM) was defined as the difference in the C2-7 Cobb angle between flexion and extension. The C2-7 sagittal vertical axis (C2-7 SVA) was measured as the distance from the posterosuperior corner of C7 to the vertical line passing through the centroid of the C2 vertebral body. The T1 slope was determined as the angle between the superior endplate of T1 and a horizontal reference line. 5, Statistical analysis All continuous variables were tested for normality using the Shapiro-Wilk test. Continuous variables were analyzed using Student's t-test. Categorical variables were analyzed using a chi-square test. All data management and analyses were conducted using IBM SPSS Statistics version 26.0 (IBM, Armonk, New York, USA). Statistical significance was set at a p-value of < 0.05. Results 1, Demographic and Surgical Characteristics In total, 109 patients met the inclusion criteria and were included in the study. Among these, 66 were included in the LP group, 25 in the LMS group and 18 in the PS group. The patients' demographic and surgical data were summarized in Table 1 . There were no significant differences in average age, sex ratio, body mass index, smoking status, drinking habits, duration of symptoms and ASA class between any two of the three groups. Operative durations varied significantly, with means of 109.2 ± 51.2 minutes in the LP group, 137.7 ± 58.2 minutes in the LMS group, and 268.8 ± 100.7 minutes in the PS group (P = 0.038). Blood loss during surgery was also notably higher in the PS group, with an average of 415.0 ± 202.9 ml compared to 137.4 ± 140.9 ml in the LP group (P = 0.000) and 221.0 ± 261.2 ml in the LMS group (P = 0.034). The hospital stay duration was significantly longer for the PS group (13.1 ± 7.6 days) compared to the LP (5.8 ± 2.5 days) and LMS groups (6.3 ± 3.1 days). The average follow-up time was 100.4 ± 15.4 days. Table 1 Demographic and surgical characteristics of patients. Characteristic LP (n = 66) LMS (n = 25) PS (n = 18) P Value LP vs. LMS LP vs.PS LMS vs. PS Age (years) 57.2 ± 10.4 55.3 ± 11.0 54.3 ± 8.7 0.469 0.324 0.782 Sex (male/female) 44/22 20/5 12/6 0.214 0.064 0.436 Body mass index (kg/m2) 25.6 ± 3.3 25.1 ± 3.1 26.7 ± 3.2 0.541 0.383 0.220 Smoking (smokers) 11 7 5 0.226 0.287 0.987 Drinking (drinkers) 7 4 3 0.481 0.482 0.953 Duration of symptoms (months) 33.6 ± 50.3 31.7 ± 56.5 45.2 ± 60.9 0.883 0.473 0.514 ASA class (Ⅰ/Ⅱ/Ⅲ) 18/45/3 5/19/1 3/14/1 0.760 0.653 0.941 Number of segments operated (n) 4.9 ± 0.6 5.3 ± 0.8 5.3 ± 0.8 0.016 0.034 0.946 Operative duration (min) 109.2 ± 51.2 137.7 ± 58.2 268.8 ± 100.7 0.038 0.000 0.000 Blood loss (ml) 137.4 ± 140.9 221.0 ± 261.2 415.0 ± 202.9 0.072 0.000 0.034 Hospital stay (days) 5.8 ± 2.5 6.3 ± 3.1 13.1 ± 7.6 0.488 0.000 0.001 Follow-up period (days) 101.1 ± 17.2 98.9 ± 10.2 104.5 ± 21.2 0.593 0.739 0.934 2, Clinical Outcomes Clinical outcomes across the three groups are summarized in Table 2 . Significant differences were observed in mJOA scores at follow-up, with the PS group demonstrating lower scores (12.8 ± 2.9) compared to both LP (15.4 ± 1.7, P 0.05). VAS changes revealed distinct patterns: the PS group exhibited significant pain reduction (preoperative 3.8 ± 2.2 vs. follow-up 2.6 ± 1.8), contrasting with minimal changes in LP and LMS groups. NDI and SF-36 scores showed no statistically significant differences between groups at follow-up. However, preoperative NDI scores trended higher in the PS group (13.4 ± 9.0) compared to LP (9.5 ± 7.9, P = 0.125) and LMS groups (9.0 ± 9.6, P = 0.194). SF36-PCS and SF36-MCS component scores remained stable across all groups throughout follow-up, with no significant intergroup variations (P > 0.05 for all comparisons). Table 2 Comparison of clinical parameters in the 3 groups Parameter LP (n = 66) LMS (n = 25) PS (n = 18) P Value LP vs. LMS LP vs.PS LMS vs. PS mJOA Pre-op 12.7 ± 2.3 12.8 ± 3.3 11.1 ± 2.3 0.927 0.027 0.124 Follow-up 15.4 ± 1.7 15.6 ± 1.5 12.8 ± 2.9 0.601 0.000 0.002 Recovery Rate (%) 56.3 ± 45.2 58.7 ± 65.8 40.4 ± 36.2 0.856 0.344 0.465 VAS Pre-op 2.3 ± 2.4 2.0 ± 2.0 3.8 ± 2.2 0.607 0.051 0.031 Follow-up 2.6 ± 2.0 2.3 ± 2.2 2.6 ± 1.8 0.526 0.940 0.662 Improvement -0.2 ± 2.8 -0.3 ± 2.7 1.9 ± 2.0 0.877 0.046 0.043 NDI Pre-op 9.5 ± 7.9 9.0 ± 9.6 13.4 ± 9.0 0.820 0.125 0.194 Follow-up 8.1 ± 6.6 9.9 ± 8.3 11.8 ± 12.3 0.310 0.194 0.704 SF36-PCS Pre-op 48.6 ± 18.4 45.5 ± 12.6 44.2 ± 20.5 0.466 0.520 0.837 Follow-up 48.0 ± 14.3 46.9 ± 15.7 45.8 ± 14.6 0.765 0.601 0.831 SF36-MCS Pre-op 54.0 ± 21.6 55.3 ± 17.5 46.3 ± 22.2 0.815 0.285 0.221 Follow-up 52.7 ± 16.2 50.6 ± 17.6 45.7 ± 13.7 0.623 0.130 0.375 3, Cervical Sagittal Balance Parameters Cervical sagittal balance parameters are summarized in Table 3 . The C2-7 Cobb angle were − 5.2 ± 7.0° in the LP group, -2.6 ± 7.1° in the LMS group, and − 0.4 ± 9.4° in the PS group preoperatively. Surgical correction of the C2-7 Cobb angle was most pronounced in the PS group (Fig. 4 ), with a marked improvement from preoperative to postoperative values (Δ8.6 ± 11.7°). In contrast, both LP and LMS groups exhibited minimal intraoperative changes (LP: Δ3.8 ± 7.8°; LMS: Δ3.4 ± 7.7°), indicating limited corrective efficacy in the LMS group. Postoperatively, all groups demonstrated progressive reductions in C2-7 Cobb angle during follow-up. The postoperative C2-7 Cobb angles for the LP, LMS, and PS groups were − 1.45.2, -0.86.3, and 2.28.9, respectively. The LP group showed a decline of 1.2 ± 7.4°, while the LMS and PS groups exhibited reductions of -4.5 ± 4.8° and − 5.9 ± 8.3°, respectively. Range of motion (ROM) at follow-up was significantly reduced in LMS (16.3 ± 10.2°) and PS (15.5 ± 11.3°) groups compared to LP (26.6 ± 10.5°, both P 0.05). Table 3 Comparison of cervical sagittal balance parameters in the 3 groups Parameter LP (n = 66) LMS (n = 25) PS (n = 18) P Value LP vs. LMS LP vs.PS LMS vs. PS C2-7 Cobb angle (°) Pre-op -5.2 ± 7.0 -2.6 ± 7.1 -0.4 ± 9.4 0.146 0.033 0.435 Post-op -1.4 ± 8.2 0.8 ± 11.6 8.6 ± 7.7 0.345 0.001 0.065 Follow-up -2.6 ± 9.6 -3.7 ± 13.0 4.2 ± 10.0 0.691 0.033 0.064 ROM (°) Pre-op 40.9 ± 12.2 40.4 ± 21.8 34.9 ± 16.8 0.897 0.118 0.415 Follow-up 26.6 ± 10.5 16.3 ± 10.2 15.5 ± 11.3 0.000 0.001 0.830 C2-7 SVA (mm) Pre-op 16.9 ± 9.2 18.6 ± 11.7 14.9 ± 9.4 0.529 0.458 0.333 Follow-up 16.8 ± 9.3 21.5 ± 10.0 18.0 ± 11.7 0.060 0.685 0.371 T1 slope (°) Pre-op 17.2 ± 6.1 15.4 ± 5.5 15.4 ± 6.0 0.258 0.344 0.994 Follow-up 15.9 ± 6.6 14.7 ± 6.2 16.9 ± 6.6 0.452 0.620 0.315 Changes in C2-7 Cobb angle (°) Pre-op to Post-op 3.8 ± 7.8 3.4 ± 7.7 8.6 ± 11.7 0.840 0.105 0.150 Post-op to Follow-up -1.2 ± 7.4 -4.5 ± 4.8 -5.9 ± 8.3 0.061 0.085 0.567 4, Surgical Complications Surgical complication rates varied among the three groups, with the highest rate observed in the PS group (27.8%), followed by the LMS group (16.0%) and the LP group (9.1%). The difference between the LP and PS groups reached statistical significance (P = 0.037). In the LP group, complications included 3 cases of cerebrospinal fluid leakage, 1 case of C5 palsy, 1 case of infection, and 1 case of nerve root edema. The LMS group reported 3 cases of C5 palsy and 1 case of infection. The PS group experienced 3 cases of cerebrospinal fluid leakage, 1 case of C5 palsy, and 1 case of infection. Discussion In this study, we compared the outcomes of posterior surgery without fixation (standalone LP) and with fixation (LMS and PS) for the treatment of multilevel cervical stenosis with kyphosis. Short-term follow-up data revealed that the clinical outcomes of surgery without fixation were superior in this patient cohort (enhanced neurological recovery and a lower incidence of surgical complications). This result may be attributed to the following reasons: ①LP did not exacerbate existing cervical kyphosis; ②LMS fixation demonstrated limited corrective efficacy in cervical kyphosis; ③while PS fixation achieved superior sagittal correction, this technique was associated with higher surgical risks and procedural complexity, which may lead to a higher incidence of complications. Cervical kyphosis is associated with the severity of preoperative myelopathy 15 , and its surgical strategy differs from that of normal cervical lordosis. Although LP is one of the most common surgical procedures in cervical spine surgery, its application in cervical kyphosis requires cautious consideration. The kyphotic sagittal alignment of the bony structures restricts posterior spinal cord migration, resulting in persistent anterior dural compression despite adequate posterior decompression. Several studies have reported that preoperative cervical kyphosis worsens the surgical outcomes of posterior decompression in patients with CSM 3 5 . Therefore, posterior screw fixation combined with correction is considered an appropriate treatment for cervical kyphosis. Mahesh et al. 16 conducted a retrospective analysis of patients with multilevel cervical myelopathy and kyphosis treated with PS fixation and kyphosis correction. By measuring the spinal canal length, they found that this approach could reduce the spinal canal length, and there was a positive correlation between canal shortening and clinical improvement. However, some evidences suggests that even in the presence of kyphosis, LP can yield satisfactory clinical outcomes 7 17 – 19 . Chiba et al. 18 reported that LP can lead to good neurological recovery and obviate the need for planned anterior surgery in some patients with cervical kyphosis. They considered that the reduction in vertical height might contribute to neurological recovery. Eastlack et al. 19 compared the clinical outcomes of patients with mild flexible cervical deformity who underwent corrective surgery versus those who did not. They found that the clinical outcomes of the 2 groups were similar. The overall incidence of complications in patients who underwent corrective surgery increased with the complexity of the osteotomy. Therefore, they suggested that ideal radiographic correction may not be necessary for mild flexible cervical deformity. Our results also corroborate the aforementioned viewpoints: standalone LP demonstrated non-inferiority in neurological improvement and quality of life compared to patients who underwent fixation procedure. However, patients who underwent PS fixation experienced greater improvement in postoperative neck pain. Notably, despite comparable improvement rates, mJOA scores at follow-up remained significantly lower in the PS group, potentially indicating a limited effect on neurological improvement. The reasons may be speculated as follows: ① patients who underwent PS fixation had relatively more severe preoperative myelopathy; ② Iatrogenic spinal cord stress during deformity correction. Miyamoto et al 3 . also compared the clinical outcomes of standalone LP and posterior reconstructive surgery with fixation for the treatment of CSM with local kyphotic deformity. They found that the clinical outcomes of posterior reconstructive surgery were superior to LP, which is in contrast to our findings. We have several hypotheses to explain this discrepancy: ①the criteria for inclusion of patients with cervical kyphosis differed, with our patients having a milder degree of kyphosis; ②variations in surgeons’ judgment of surgical indications and surgical skill may impact clinical outcomes. They compared the use of LMS and PS combined against standalone LP, whereas our study included a larger patient population and compared the outcomes of fixation with LMS and PS separately, as these fixation methods may yield different results. The present study found that even without fixation, there was a slight improvement in the mean C2-7 Cobb angle postoperatively. Similarly, Nagoshi et al. 7 analyzed the outcomes of patients with cervical kyphosis and mild kyphosis who underwent unilateral open-door laminoplasty with at least 2 years of follow-up, and found that cervical curvature improved even in patients with kyphosis after LP. In patients with kyphosis, the improvement in neurological function, pain, and quality of life was satisfactory. The results of the present study indicate that LMS fixation provided no significant corrective effect on non-severe kyphosis, whereas PS fixation significantly improved cervical alignment. All groups exhibited minor alignment deterioration during follow-up, though PS fixation maintained better curvature preservation. Compared to standalone LP, LMS fixation required more operative time and blood loss, yet it did not demonstrate better neurological recovery or reduction in neck pain. Additionally, we found that in patients undergoing fixation procedure, cSVA increased at follow-up. There is an association between the cervical curvature and the T1 slope of non-severe kyphosis 20 , suggesting a delicate sagittal balance in these patients. When fixation surgery (with or without correction) is performed, this balance may be disrupted, leading to realignment of the sagittal spinal alignment. However, due to the short follow-up period, long-term radiological outcomes require further investigation in future studies. In our study, patients undergoing fixation procedure received LP instead of the traditional laminectomy, which is believed to reduce the risks of postoperative neck pain, subsequent neurological deterioration, and iatrogenic spinal cord injury 21 . However, our results revealed that there was still a high complication rate in patients undergoing fixation procedure, particularly in PS cases. We speculate that this may be due to the fact that fixation procedure often involve corrective maneuvers, which can lead to damage to dura mater and spinal cord. After kyphosis correction, the posterior column structures of the cervical spine are compressed, resulting in foraminal stenosis and the upward migration of the superior articular processes, which directly compress the C5 nerve root, thereby increasing the risk of C5 nerve root palsy. Additionally, longer operative duration and technical demands of instrumented procedures also elevate general complication risks. When interpreting the current results, several limitations must be considered. Firstly, this is a retrospective study, making it difficult to control for biases between groups. Secondly, with a follow-up period of 3 months, the study can only reflect short-term postoperative outcomes, and a longer follow-up period is needed to further evaluate the clinical outcomes of posterior fixation versus non-fixation procedures. Thirdly, due to the limitation of sample size, this study did not differentiate between radiological types of cervical kyphosis. Future studies with larger samples are required to conduct subgroup analyses and further evaluate whether the results differ among various types of cervical kyphosis. Conclusion This retrospective study analyzed the clinical and radiographic outcomes of posterior surgeries with and without fixation procedure in patients with cervical stenosis and non-severe kyphosis. Our study results indicate that surgeries without fixation had shorter operative time and reduced blood loss. Patients without fixation procedure did not show inferior neurological recovery and quality of life compared to those with fixation procedure, and they also had a lower incidence of complications. LMS fixation failed to provide effective sagittal alignment correction or maintenance. PS fixation maintained the correction of cervical kyphosis achieved during surgery achieved and had better neck pain relief. However, its higher complication rate and potential for suboptimal neurological recovery necessitate cautious consideration. In summary, the present study suggests that it is not necessary to perform fixation procedure during posterior surgery for patients with cervical stenosis with non-severe kyphosis. Declarations Funding Ethics approval and consent to participate: This retrospective study was approved by Peking University Third Hospital Medical Science Research Ethics Committee (Number: M2022752) Consent for publication: All participants provided consent for the publication of anonymized data derived from this study. Where applicable, consent for the use of identifiable images or personal details was obtained in writing. Availability of data and materials: The datasets generated and analyzed during the current study are not publicly available due to privacy restrictions. However, anonymized or aggregated data supporting the findings may be made available from the corresponding author upon reasonable request, subject to ethical approvals and data protection agreements. Competing interests: The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding: This work was partially supported by National Key Research and Development Program of China (2023YFC3604400) Authors' contributions: FZ, XY and HC conceived and designed the study. HC, XY, PW and SP contributed to the acquisition of data. HC and XY analyzed the data, discussed the results. HC wrote the manuscript. YZ and XC edited the manuscript. YS and FZ supervised the investigation and reviewed the manuscript. Acknowledgements: N.A. References Grodzinski B, Durham R, Mowforth O, et al. The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review. Age Ageing 2021;50(3):705-15. doi: 10.1093/ageing/afaa236 [published Online First: 2020/11/22] Scheer JK, Lau D, Smith JS, et al. Alignment, Classification, Clinical Evaluation, and Surgical Treatment for Adult Cervical Deformity: A Complete Guide. Neurosurgery 2021;88(4):864-83. doi: 10.1093/neuros/nyaa582 [published Online First: 2021/02/07] Miyamoto H, Maeno K, Uno K, et al. Outcomes of surgical intervention for cervical spondylotic myelopathy accompanying local kyphosis (comparison between laminoplasty alone and posterior reconstruction surgery using the screw-rod system). Eur Spine J 2014;23(2):341-6. doi: 10.1007/s00586-013-2923-1 [published Online First: 2013/08/02] Qian S, Wang Z, Jiang G, et al. Efficacy of Laminoplasty in Patients with Cervical Kyphosis. Med Sci Monit 2018;24:1188-95. doi: 10.12659/msm.909140 [published Online First: 2018/02/28] Suda K, Abumi K, Ito M, et al. Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2003;28(12):1258-62. doi: 10.1097/01.Brs.0000065487.82469.D9 [published Online First: 2003/06/18] Uchida K, Nakajima H, Sato R, et al. Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression. J Neurosurg Spine 2009;11(5):521-8. doi: 10.3171/2009.2.Spine08385 [published Online First: 2009/11/26] Nagoshi N, Nori S, Tsuji O, et al. Surgical and Functional Outcomes of Expansive Open-Door Laminoplasty for Patients With Mild Kyphotic Cervical Alignment. Neurospine 2021;18(4):749-57. doi: 10.14245/ns.2142792.396 [published Online First: 2022/01/10] Coe JD, Vaccaro AR, Dailey AT, et al. Lateral mass screw fixation in the cervical spine: a systematic literature review. J Bone Joint Surg Am 2013;95(23):2136-43. doi: 10.2106/jbjs.L.01522 [published Online First: 2013/12/07] Abumi K, Shono Y, Taneichi H, et al. Correction of cervical kyphosis using pedicle screw fixation systems. Spine (Phila Pa 1976) 1999;24(22):2389-96. doi: 10.1097/00007632-199911150-00017 [published Online First: 1999/12/10] Duan Y, Zhang H, Min SX, et al. Posterior cervical fixation following laminectomy: a stress analysis of three techniques. Eur Spine J 2011;20(9):1552-9. doi: 10.1007/s00586-011-1711-z [published Online First: 2011/02/15] Abumi K, Ito M, Sudo H. Reconstruction of the subaxial cervical spine using pedicle screw instrumentation. Spine (Phila Pa 1976) 2012;37(5):E349-56. doi: 10.1097/BRS.0b013e318239cf1f [published Online First: 2011/10/25] Lee S, Cho DC, Roh SW, et al. Cervical Alignment Following Posterior Cervical Fusion Surgery: Cervical Pedicle Screw Versus Lateral Mass Screw Fixation. Spine (Phila Pa 1976) 2021;46(10):E576-e83. doi: 10.1097/brs.0000000000003845 [published Online First: 2020/12/09] Zhou LP, Zhang ZG, Li D, et al. Robotics in Cervical Spine Surgery: Feasibility and Safety of Posterior Screw Placement. Neurospine 2023;20(1):329-39. doi: 10.14245/ns.2244952.476 [published Online First: 2023/04/06] Pal D, Bayley E, Magaji SA, et al. Freehand determination of the trajectory angle for cervical lateral mass screws: how accurate is it? Eur Spine J 2011;20(6):972-6. doi: 10.1007/s00586-011-1694-9 [published Online First: 2011/02/01] Wu B, Liu B, Sang D, et al. The association between cervical focal kyphosis and myelopathy severity in patients with cervical spondylotic myelopathy before surgery. Eur Spine J 2021;30(6):1501-08. doi: 10.1007/s00586-021-06771-x [published Online First: 2021/03/01] Mahesh B, Upendra B, Vijay S, et al. Addressing Stretch Myelopathy in Multilevel Cervical Kyphosis with Posterior Surgery Using Cervical Pedicle Screws. Asian Spine J 2016;10(6):1007-17. doi: 10.4184/asj.2016.10.6.1007 [published Online First: 2016/12/21] Ninomiya K, Okuyama K, Aoyama R, et al. Surgical Outcomes of Selective Laminectomy for Patients With Cervical Kyphosis: A Retrospective Study of 379 Cases. Global Spine J 2023;13(7):1777-86. doi: 10.1177/21925682211049799 [published Online First: 2021/11/02] Chiba K, Toyama Y, Watanabe M, et al. Impact of longitudinal distance of the cervical spine on the results of expansive open-door laminoplasty. Spine (Phila Pa 1976) 2000;25(22):2893-8. doi: 10.1097/00007632-200011150-00010 [published Online First: 2000/11/14] Eastlack RK, Lakomkin N, Tran S, et al. Necessity of posterior osteotomies for mild flexible cervical deformity correction. J Neurosurg Spine 2024;41(6):757-64. doi: 10.3171/2024.5.Spine231223 [published Online First: 2024/09/13] Ames CP, Blondel B, Scheer JK, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976) 2013;38(22 Suppl 1):S149-60. doi: 10.1097/BRS.0b013e3182a7f449 [published Online First: 2013/10/23] Yeh KT, Lee RP, Chen IH, et al. Laminoplasty instead of laminectomy as a decompression method in posterior instrumented fusion for degenerative cervical kyphosis with stenosis. J Orthop Surg Res 2015;10:138. doi: 10.1186/s13018-015-0280-y [published Online First: 2015/09/05] 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-7292535","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504754874,"identity":"c91d11c6-e3a8-4f8f-9c91-7a99d91d4419","order_by":0,"name":"Hongyu Chen","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hongyu","middleName":"","lastName":"Chen","suffix":""},{"id":504754875,"identity":"a9695203-2c61-4c35-9653-ffae20d11451","order_by":1,"name":"Xiaoxiong Yang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxiong","middleName":"","lastName":"Yang","suffix":""},{"id":504754876,"identity":"36c55dcc-072f-4b15-ba04-329501fb77f1","order_by":2,"name":"Pinhan Wu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pinhan","middleName":"","lastName":"Wu","suffix":""},{"id":504754877,"identity":"addbd9d8-85d8-4ffa-b291-5b4b48e3a1fe","order_by":3,"name":"Shengfa Pan","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shengfa","middleName":"","lastName":"Pan","suffix":""},{"id":504754878,"identity":"9159ca93-7ea6-4ee8-b057-d6dc7f523f21","order_by":4,"name":"Yanbin Zhao","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanbin","middleName":"","lastName":"Zhao","suffix":""},{"id":504754879,"identity":"c4648e8b-6ae6-4833-b86d-d053d2dc2e5b","order_by":5,"name":"Xin Chen","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Chen","suffix":""},{"id":504754881,"identity":"cc4db87b-d4a8-48c3-81c0-a36d32f0e4d4","order_by":6,"name":"Yu Sun","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Sun","suffix":""},{"id":504754883,"identity":"01eb4acf-778a-4516-8e65-b34793f0c4a0","order_by":7,"name":"Feifei Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIie3RsWvCQBTH8RcOzuU06+8ImH8hoVAdCv1XTgJOHZyKQ7GBQKaCa6T9I+qi64VAXELnrFncRXAsjXUqhTPdOtwXbnnwgXs8IpvtP4b2zQkuMaad+DzRXUhFkDHj6k+EZEwi6Eb816SEno/h9sSpWaU0HNTKOc4MxHkrp9AVIJP+NlyndCNrxbzMQBgebr1DikVQ9DeySWnyXivOhIHwliD/BO4LsT+T56tEfJMYCJjgsv2YCq4RYBqNdQmg4KMw+0C4qprEMxE/i/JaPy3gLot98/J45w92UX40kR970eVMl/N0JjabzWb73Rc780eBTey07wAAAABJRU5ErkJggg==","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":true,"prefix":"","firstName":"Feifei","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2025-08-04 15:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7292535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7292535/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89981116,"identity":"de17d746-be31-4776-9adf-dfa3f817661a","added_by":"auto","created_at":"2025-08-27 06:24:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":177242,"visible":true,"origin":"","legend":"\u003cp\u003eLateral cervical X-ray images of the cervical spine before (A) and after (B) laminoplasty.\u003c/p\u003e","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292535/v1/e2a2c8e790aeb4655b8431cc.jpg"},{"id":89981098,"identity":"a616d053-8da4-4162-9074-ec3304049811","added_by":"auto","created_at":"2025-08-27 06:24:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":184135,"visible":true,"origin":"","legend":"\u003cp\u003eLateral cervical X-ray images of the cervical spine before (A) and after (B) lateral mass screw fixation.\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292535/v1/7d053625c0fc2c25d9b6c4d7.jpg"},{"id":89981081,"identity":"38bbdc81-ffb1-4e17-ba43-74929c708bc1","added_by":"auto","created_at":"2025-08-27 06:24:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":209623,"visible":true,"origin":"","legend":"\u003cp\u003eLateral cervical X-ray images of the cervical spine before (A) and after (B) pedicle screw fixation.\u003c/p\u003e","description":"","filename":"fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292535/v1/9f8899839fde22cac77d1ad3.jpg"},{"id":89981073,"identity":"ab49631f-8919-42c6-b754-044cfbaba69b","added_by":"auto","created_at":"2025-08-27 06:24:12","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":49584,"visible":true,"origin":"","legend":"\u003cp\u003eC2-7 Cobb angle form standalone laminoplasty, lateral mass screw fixation and pedicle screw fixation at preoperation, postoperation, and follow-up.\u003c/p\u003e","description":"","filename":"fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292535/v1/33897cb55d0c8696c695757a.jpg"},{"id":95655099,"identity":"fe3b64e1-e1b8-4c33-b89a-22c4fa3d80f4","added_by":"auto","created_at":"2025-11-11 16:14:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1439996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7292535/v1/5dc65272-0ef6-446e-aea3-980fc8934817.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is Fixation Procedure Necessary in Posterior Approach Surgery for Cervical Stenosis with Non-Severe Kyphosis?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultilevel cervical spondylotic myelopathy (CSM) induces neurological deficits through spinal cord compression\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Degenerative changes in the facet joints and intervertebral discs may lead to sagittal imbalance, contributing to cervical kyphosis\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. To halt functional deterioration, surgical intervention is frequently considered. Some scholars\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e regarded preoperative cervical kyphosis as a relative contraindication for standalone posterior decompression due to the reduced posterior shift of the spinal cord, which could interfere with indirect anterior decompression. However, some studies have shown that standalone posterior decompression does not necessarily result in inferior neurological outcomes. Uchida et al.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e compared the surgical outcomes of anterior decompression and fusion versus laminoplasty (LP) in patients with cervical kyphosis. They found that although patients undergoing laminoplasty alone still had cervical kyphosis, both groups exhibited comparable neurological improvement. Similarly, Nagoshi et al.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e reported that patients with mild cervical kyphosis who underwent laminoplasty also achieved favorable clinical outcomes. These findings suggest that there is no consensus on the optimal treatment for patients with CSM and preoperative cervical kyphosis.\u003c/p\u003e\u003cp\u003ePosterior decompression combined with screw fixation represents a classical surgical strategy for multilevel cervical stenosis with kyphosis. Fixation techniques include lateral mass screws (LMS) and pedicle screws (PS). The use of LMS in posterior cervical fixation and stabilization has become increasingly common\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. When correcting cervical kyphosis with LMS, anterior fusion may also be required\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. From a biomechanical perspective, PS provide greater stability than LMS, offering higher pullout strength and can be used for kyphosis correction\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, their widespread application is limited by a steeper learning curve and the potential risk of catastrophic complications, such as arterial injury\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. For cases of non-severe cervical kyphosis, the purported advantages of PS fixation, such as higher pullout strength and greater resistance to fixation failure, may not be clinically relevant.\u003c/p\u003e\u003cp\u003eThis study aims to clarify whether fixation procedure is necessary for patients with degenerative cervical spinal stenosis and non-severe kyphotic deformity by comparing clinical and radiological outcomes between those who underwent posterior surgery with and without fixation. To differentiate screw types, we categorize the fixation group into those using LMS and those using PS for comparison.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e1, Patient characteristics\u003c/h3\u003e\u003cp\u003e This retrospective study was approved by the institutional review board of our institute (number: M2022752). Patients diagnosed with multi-level cervical spinal canal stenosis and degenerative cervical kyphosis who underwent posterior surgery at our institution between January 2013 and January 2024 were retrospectively reviewed. The inclusion criteria were as follows: (1) aged between 18 and 75 years; (2) marked degenerative cervical kyphosis through cervical standing lateral plain films (C2-7 Cobb angle \u0026lt; 0° or local kyphotic angle \u0026gt; 10°); (3) complete clinical and radiological imaging data. The exclusion criteria were as follows: (1) combinations with anterior surgery; (2) severe kyphosis (C2-7 Cobb angle \u0026lt; -25°) (3) with cervical deformities such as scoliosis, atlantoaxial dislocation, basilar invagination, atlanto-occipital fusion, cervical segmentation defects, or spina bifida; (4) pathologies requiring differential management (tumors, fractures, infections or congenital cervical kyphosis); (5) prior cervical spine surgery; (6) comorbidities affecting neurological assessments (intracranial lesions, intramedullary pathologies, myasthenia gravis, intellectual disability, or neuropsychiatric disorders).\u003c/p\u003e\u003ch3\u003e2, Operative technique\u003c/h3\u003e\u003cp\u003ePatients were stratified into three groups based on surgical approach: laminoplasty alone (LP), laminoplasty with lateral mass screw fixation (hereinafter referred to as LMS), and laminoplasty with pedicle screw fixation (hereinafter referred to as PS). All surgical procedures across the three groups were performed by the same team of experienced spine surgeons and with standardized preoperative planning. After securing the head in a Mayfield three-pin fixation device, the patient was positioned prone. A midline incision exposed the posterior cervical elements. In the LP group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), surgical procedures were performed as follows: On the right side, a trough was created at the lamina-facet junction by removing the outer cortical bone to serve as the hinge, while a complete osteotomy through both the inner and outer cortical layers was performed at the lamina-facet junction on the left side. The laminar door was then elevated and secured in the expanded position using titanium miniplates or titanium cables. Throughout the procedure, meticulous care was taken to preserve the bilateral deep extensor musculature and ligamentous structures.\u003c/p\u003e\u003cp\u003eIn the LMS group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the procedure involved lateral mass screw placement and LP. Lateral mass screw were placed bilaterally using the Magerl technique\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Appropriately sized rods were selected, contoured to match the physiological cervical lordosis, and secured to the lateral masses with screws. LP was then performed according to the preoperative surgical plan.\u003c/p\u003e\u003cp\u003eIn the PS group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), polyaxial titanium pedicle screws were inserted into the pedicles of the targeted fusion segments. Fluoroscopy was utilized to confirm optimal screw trajectory and depth. Titanium rods of appropriate length were contoured to an adequate curvature to restore cervical lordotic curvature and subsequently connected to the screw heads. During rod-screw fixation, a distraction-compression maneuver was applied to cranial and caudal screws to facilitate reduction, while manual ventral pressure was exerted on the mid-level spinous processes and laminae to assist kyphosis correction. LP was then performed following the standardized protocol.\u003c/p\u003e\u003ch3\u003e3, Clinical evaluation\u003c/h3\u003e\u003cp\u003ePatient demographics, surgical characteristics, preoperative baseline and follow-up clinical data were collected. Modified Japanese Orthopedic Association (mJOA) score, Visual Analog Scale (VAS) for neck pain, Neck Disability Index (NDI), and the Short Form 36 (SF36) health survey were recorded before surgery and at follow-up.\u003c/p\u003e\u003cp\u003eThe neurological recovery rate was calculated using the following formula: (postoperative JOA score - preoperative score)/(17 - preoperative score)×100%. Improvement in neck pain was assessed by calculating the difference between postoperative and preoperative VAS scores (postoperative VAS - preoperative VAS).\u003c/p\u003e\u003ch3\u003e4, Radiographic assessment\u003c/h3\u003e\u003cp\u003ePreoperative, postoperative and follow-up radiographic assessment were carried out by 2 independent observers whose results were averaged. The intraobserver errors were less than 5%. The C2-7 Cobb angle was measured on standing lateral radiographs as the angle formed by the intersection of lines drawn along the inferior endplates of C2 and C7, with positive values indicating lordosis and negative values indicating kyphosis. The cervical range of motion (ROM) was defined as the difference in the C2-7 Cobb angle between flexion and extension. The C2-7 sagittal vertical axis (C2-7 SVA) was measured as the distance from the posterosuperior corner of C7 to the vertical line passing through the centroid of the C2 vertebral body. The T1 slope was determined as the angle between the superior endplate of T1 and a horizontal reference line.\u003c/p\u003e\u003ch3\u003e5, Statistical analysis\u003c/h3\u003e\u003cp\u003eAll continuous variables were tested for normality using the Shapiro-Wilk test. Continuous variables were analyzed using Student's t-test. Categorical variables were analyzed using a chi-square test. All data management and analyses were conducted using IBM SPSS Statistics version 26.0 (IBM, Armonk, New York, USA). Statistical significance was set at a p-value of \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1, Demographic and Surgical Characteristics\u003c/h3\u003e\n\u003cp\u003eIn total, 109 patients met the inclusion criteria and were included in the study. Among these, 66 were included in the LP group, 25 in the LMS group and 18 in the PS group. The patients' demographic and surgical data were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no significant differences in average age, sex ratio, body mass index, smoking status, drinking habits, duration of symptoms and ASA class between any two of the three groups.\u003c/p\u003e\u003cp\u003eOperative durations varied significantly, with means of 109.2\u0026thinsp;\u0026plusmn;\u0026thinsp;51.2 minutes in the LP group, 137.7\u0026thinsp;\u0026plusmn;\u0026thinsp;58.2 minutes in the LMS group, and 268.8\u0026thinsp;\u0026plusmn;\u0026thinsp;100.7 minutes in the PS group (P\u0026thinsp;=\u0026thinsp;0.038). Blood loss during surgery was also notably higher in the PS group, with an average of 415.0\u0026thinsp;\u0026plusmn;\u0026thinsp;202.9 ml compared to 137.4\u0026thinsp;\u0026plusmn;\u0026thinsp;140.9 ml in the LP group (P\u0026thinsp;=\u0026thinsp;0.000) and 221.0\u0026thinsp;\u0026plusmn;\u0026thinsp;261.2 ml in the LMS group (P\u0026thinsp;=\u0026thinsp;0.034). The hospital stay duration was significantly longer for the PS group (13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 days) compared to the LP (5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 days) and LMS groups (6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 days). The average follow-up time was 100.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4 days.\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\u003eDemographic and surgical characteristics of patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLP (n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLMS (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePS (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLP vs. LMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLP vs.PS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLMS vs. PS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.469\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.782\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (male/female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44/22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20/5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.064\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.436\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (kg/m2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.541\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking (smokers)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.987\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrinking (drinkers)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.481\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.482\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.953\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of symptoms (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.6\u0026thinsp;\u0026plusmn;\u0026thinsp;50.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;56.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.2\u0026thinsp;\u0026plusmn;\u0026thinsp;60.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.883\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.473\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.514\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA class (Ⅰ/Ⅱ/Ⅲ)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18/45/3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5/19/1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3/14/1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.760\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.653\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.941\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of segments operated (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.946\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e109.2\u0026thinsp;\u0026plusmn;\u0026thinsp;51.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e137.7\u0026thinsp;\u0026plusmn;\u0026thinsp;58.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e268.8\u0026thinsp;\u0026plusmn;\u0026thinsp;100.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e137.4\u0026thinsp;\u0026plusmn;\u0026thinsp;140.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e221.0\u0026thinsp;\u0026plusmn;\u0026thinsp;261.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e415.0\u0026thinsp;\u0026plusmn;\u0026thinsp;202.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.488\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up period (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e104.5\u0026thinsp;\u0026plusmn;\u0026thinsp;21.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.593\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.739\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.934\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e2, Clinical Outcomes\u003c/h3\u003e\n\u003cp\u003eClinical outcomes across the three groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Significant differences were observed in mJOA scores at follow-up, with the PS group demonstrating lower scores (12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9) compared to both LP (15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LMS groups (15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5, P\u0026thinsp;=\u0026thinsp;0.002). The recovery rate of mJOA showed no statistically significant intergroup differences (56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;45.2% vs. 58.7\u0026thinsp;\u0026plusmn;\u0026thinsp;65.8% vs. 40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;36.2%, all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eVAS changes revealed distinct patterns: the PS group exhibited significant pain reduction (preoperative 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 vs. follow-up 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8), contrasting with minimal changes in LP and LMS groups.\u003c/p\u003e\u003cp\u003eNDI and SF-36 scores showed no statistically significant differences between groups at follow-up. However, preoperative NDI scores trended higher in the PS group (13.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0) compared to LP (9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9, P\u0026thinsp;=\u0026thinsp;0.125) and LMS groups (9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6, P\u0026thinsp;=\u0026thinsp;0.194). SF36-PCS and SF36-MCS component scores remained stable across all groups throughout follow-up, with no significant intergroup variations (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all comparisons).\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 clinical parameters in the 3 groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLP (n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLMS (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePS (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLP vs. LMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLP vs.PS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLMS vs. PS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emJOA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e11.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.124\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.601\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecovery Rate (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;45.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e58.7\u0026thinsp;\u0026plusmn;\u0026thinsp;65.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;36.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.856\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.465\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVAS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.526\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.940\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.662\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImprovement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNDI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e13.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.194\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.310\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.704\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF36-PCS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e48.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;20.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.520\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.837\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e48.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e46.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e45.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.765\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.601\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.831\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF36-MCS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e54.0\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e46.3\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.285\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.221\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e52.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e45.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.623\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.375\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e3, Cervical Sagittal Balance Parameters\u003c/h3\u003e\n\u003cp\u003eCervical sagittal balance parameters are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The C2-7 Cobb angle were \u0026minus;\u0026thinsp;5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u0026deg; in the LP group, -2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u0026deg; in the LMS group, and \u0026minus;\u0026thinsp;0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u0026deg; in the PS group preoperatively. Surgical correction of the C2-7 Cobb angle was most pronounced in the PS group (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with a marked improvement from preoperative to postoperative values (Δ8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u0026deg;). In contrast, both LP and LMS groups exhibited minimal intraoperative changes (LP: Δ3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u0026deg;; LMS: Δ3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u0026deg;), indicating limited corrective efficacy in the LMS group. Postoperatively, all groups demonstrated progressive reductions in C2-7 Cobb angle during follow-up. The postoperative C2-7 Cobb angles for the LP, LMS, and PS groups were \u0026minus;\u0026thinsp;1.45.2, -0.86.3, and 2.28.9, respectively. The LP group showed a decline of 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u0026deg;, while the LMS and PS groups exhibited reductions of -4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u0026deg; and \u0026minus;\u0026thinsp;5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u0026deg;, respectively.\u003c/p\u003e\u003cp\u003eRange of motion (ROM) at follow-up was significantly reduced in LMS (16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u0026deg;) and PS (15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u0026deg;) groups compared to LP (26.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u0026deg;, both P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant differences in cervical sagittal vertical axis (cSVA) or T1 slope were observed between groups preoperatively or at follow-up (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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 cervical sagittal balance parameters in the 3 groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLP (n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLMS (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePS (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLP vs. LMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLP vs.PS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLMS vs. PS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eC2-7 Cobb angle (\u0026deg;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.435\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.691\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.064\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eROM (\u0026deg;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e40.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.415\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e26.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.830\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eC2-7 SVA (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.458\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e18.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.371\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT1 slope (\u0026deg;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.258\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.994\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.452\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.620\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.315\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChanges in C2-7 Cobb angle (\u0026deg;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op to Post-op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.840\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.150\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-op to Follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.567\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003e4, Surgical Complications\u003c/h3\u003e\n\u003cp\u003eSurgical complication rates varied among the three groups, with the highest rate observed in the PS group (27.8%), followed by the LMS group (16.0%) and the LP group (9.1%). The difference between the LP and PS groups reached statistical significance (P\u0026thinsp;=\u0026thinsp;0.037).\u003c/p\u003e\u003cp\u003eIn the LP group, complications included 3 cases of cerebrospinal fluid leakage, 1 case of C5 palsy, 1 case of infection, and 1 case of nerve root edema. The LMS group reported 3 cases of C5 palsy and 1 case of infection. The PS group experienced 3 cases of cerebrospinal fluid leakage, 1 case of C5 palsy, and 1 case of infection.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we compared the outcomes of posterior surgery without fixation (standalone LP) and with fixation (LMS and PS) for the treatment of multilevel cervical stenosis with kyphosis. Short-term follow-up data revealed that the clinical outcomes of surgery without fixation were superior in this patient cohort (enhanced neurological recovery and a lower incidence of surgical complications). This result may be attributed to the following reasons: ①LP did not exacerbate existing cervical kyphosis; ②LMS fixation demonstrated limited corrective efficacy in cervical kyphosis; ③while PS fixation achieved superior sagittal correction, this technique was associated with higher surgical risks and procedural complexity, which may lead to a higher incidence of complications.\u003c/p\u003e\u003cp\u003eCervical kyphosis is associated with the severity of preoperative myelopathy\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, and its surgical strategy differs from that of normal cervical lordosis. Although LP is one of the most common surgical procedures in cervical spine surgery, its application in cervical kyphosis requires cautious consideration. The kyphotic sagittal alignment of the bony structures restricts posterior spinal cord migration, resulting in persistent anterior dural compression despite adequate posterior decompression. Several studies have reported that preoperative cervical kyphosis worsens the surgical outcomes of posterior decompression in patients with CSM\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Therefore, posterior screw fixation combined with correction is considered an appropriate treatment for cervical kyphosis. Mahesh et al.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e conducted a retrospective analysis of patients with multilevel cervical myelopathy and kyphosis treated with PS fixation and kyphosis correction. By measuring the spinal canal length, they found that this approach could reduce the spinal canal length, and there was a positive correlation between canal shortening and clinical improvement.\u003c/p\u003e\u003cp\u003eHowever, some evidences suggests that even in the presence of kyphosis, LP can yield satisfactory clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Chiba et al.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e reported that LP can lead to good neurological recovery and obviate the need for planned anterior surgery in some patients with cervical kyphosis. They considered that the reduction in vertical height might contribute to neurological recovery. Eastlack et al.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e compared the clinical outcomes of patients with mild flexible cervical deformity who underwent corrective surgery versus those who did not. They found that the clinical outcomes of the 2 groups were similar. The overall incidence of complications in patients who underwent corrective surgery increased with the complexity of the osteotomy. Therefore, they suggested that ideal radiographic correction may not be necessary for mild flexible cervical deformity.\u003c/p\u003e\u003cp\u003eOur results also corroborate the aforementioned viewpoints: standalone LP demonstrated non-inferiority in neurological improvement and quality of life compared to patients who underwent fixation procedure. However, patients who underwent PS fixation experienced greater improvement in postoperative neck pain. Notably, despite comparable improvement rates, mJOA scores at follow-up remained significantly lower in the PS group, potentially indicating a limited effect on neurological improvement. The reasons may be speculated as follows: ① patients who underwent PS fixation had relatively more severe preoperative myelopathy; ② Iatrogenic spinal cord stress during deformity correction.\u003c/p\u003e\u003cp\u003eMiyamoto et al\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. also compared the clinical outcomes of standalone LP and posterior reconstructive surgery with fixation for the treatment of CSM with local kyphotic deformity. They found that the clinical outcomes of posterior reconstructive surgery were superior to LP, which is in contrast to our findings. We have several hypotheses to explain this discrepancy: ①the criteria for inclusion of patients with cervical kyphosis differed, with our patients having a milder degree of kyphosis; ②variations in surgeons\u0026rsquo; judgment of surgical indications and surgical skill may impact clinical outcomes. They compared the use of LMS and PS combined against standalone LP, whereas our study included a larger patient population and compared the outcomes of fixation with LMS and PS separately, as these fixation methods may yield different results.\u003c/p\u003e\u003cp\u003eThe present study found that even without fixation, there was a slight improvement in the mean C2-7 Cobb angle postoperatively. Similarly, Nagoshi et al.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e analyzed the outcomes of patients with cervical kyphosis and mild kyphosis who underwent unilateral open-door laminoplasty with at least 2 years of follow-up, and found that cervical curvature improved even in patients with kyphosis after LP. In patients with kyphosis, the improvement in neurological function, pain, and quality of life was satisfactory. The results of the present study indicate that LMS fixation provided no significant corrective effect on non-severe kyphosis, whereas PS fixation significantly improved cervical alignment. All groups exhibited minor alignment deterioration during follow-up, though PS fixation maintained better curvature preservation. Compared to standalone LP, LMS fixation required more operative time and blood loss, yet it did not demonstrate better neurological recovery or reduction in neck pain. Additionally, we found that in patients undergoing fixation procedure, cSVA increased at follow-up. There is an association between the cervical curvature and the T1 slope of non-severe kyphosis\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, suggesting a delicate sagittal balance in these patients. When fixation surgery (with or without correction) is performed, this balance may be disrupted, leading to realignment of the sagittal spinal alignment. However, due to the short follow-up period, long-term radiological outcomes require further investigation in future studies.\u003c/p\u003e\u003cp\u003eIn our study, patients undergoing fixation procedure received LP instead of the traditional laminectomy, which is believed to reduce the risks of postoperative neck pain, subsequent neurological deterioration, and iatrogenic spinal cord injury\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. However, our results revealed that there was still a high complication rate in patients undergoing fixation procedure, particularly in PS cases. We speculate that this may be due to the fact that fixation procedure often involve corrective maneuvers, which can lead to damage to dura mater and spinal cord. After kyphosis correction, the posterior column structures of the cervical spine are compressed, resulting in foraminal stenosis and the upward migration of the superior articular processes, which directly compress the C5 nerve root, thereby increasing the risk of C5 nerve root palsy. Additionally, longer operative duration and technical demands of instrumented procedures also elevate general complication risks.\u003c/p\u003e\u003cp\u003eWhen interpreting the current results, several limitations must be considered. Firstly, this is a retrospective study, making it difficult to control for biases between groups. Secondly, with a follow-up period of 3 months, the study can only reflect short-term postoperative outcomes, and a longer follow-up period is needed to further evaluate the clinical outcomes of posterior fixation versus non-fixation procedures. Thirdly, due to the limitation of sample size, this study did not differentiate between radiological types of cervical kyphosis. Future studies with larger samples are required to conduct subgroup analyses and further evaluate whether the results differ among various types of cervical kyphosis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis retrospective study analyzed the clinical and radiographic outcomes of posterior surgeries with and without fixation procedure in patients with cervical stenosis and non-severe kyphosis. Our study results indicate that surgeries without fixation had shorter operative time and reduced blood loss. Patients without fixation procedure did not show inferior neurological recovery and quality of life compared to those with fixation procedure, and they also had a lower incidence of complications. LMS fixation failed to provide effective sagittal alignment correction or maintenance. PS fixation maintained the correction of cervical kyphosis achieved during surgery achieved and had better neck pain relief. However, its higher complication rate and potential for suboptimal neurological recovery necessitate cautious consideration. In summary, the present study suggests that it is not necessary to perform fixation procedure during posterior surgery for patients with cervical stenosis with non-severe kyphosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: This retrospective study was approved by Peking University Third Hospital Medical Science Research Ethics Committee (Number: M2022752)\u003c/p\u003e\n\u003cp\u003eConsent for publication: All participants provided consent for the publication of anonymized data derived from this study. Where applicable, consent for the use of identifiable images or personal details was obtained in writing.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets generated and analyzed during the current study are not publicly available due to privacy restrictions. However, anonymized or aggregated data supporting the findings may be made available from the corresponding author upon reasonable request, subject to ethical approvals and data protection agreements.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003eFunding: This work was partially supported by National Key Research and Development Program of China (2023YFC3604400)\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: FZ, XY and HC conceived and designed the study. HC, XY, PW and SP contributed to the acquisition of data. HC and XY analyzed the data, discussed the results. HC wrote the manuscript. YZ and XC edited the manuscript. \u0026nbsp;YS and FZ supervised the investigation and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: N.A.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGrodzinski B, Durham R, Mowforth O, et al. The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review. \u003cem\u003eAge Ageing\u003c/em\u003e 2021;50(3):705-15. doi: 10.1093/ageing/afaa236 [published Online First: 2020/11/22]\u003c/li\u003e\n\u003cli\u003eScheer JK, Lau D, Smith JS, et al. Alignment, Classification, Clinical Evaluation, and Surgical Treatment for Adult Cervical Deformity: A Complete Guide. \u003cem\u003eNeurosurgery\u003c/em\u003e 2021;88(4):864-83. doi: 10.1093/neuros/nyaa582 [published Online First: 2021/02/07]\u003c/li\u003e\n\u003cli\u003eMiyamoto H, Maeno K, Uno K, et al. Outcomes of surgical intervention for cervical spondylotic myelopathy accompanying local kyphosis (comparison between laminoplasty alone and posterior reconstruction surgery using the screw-rod system). \u003cem\u003eEur Spine J\u003c/em\u003e 2014;23(2):341-6. doi: 10.1007/s00586-013-2923-1 [published Online First: 2013/08/02]\u003c/li\u003e\n\u003cli\u003eQian S, Wang Z, Jiang G, et al. Efficacy of Laminoplasty in Patients with Cervical Kyphosis. \u003cem\u003eMed Sci Monit\u003c/em\u003e 2018;24:1188-95. doi: 10.12659/msm.909140 [published Online First: 2018/02/28]\u003c/li\u003e\n\u003cli\u003eSuda K, Abumi K, Ito M, et al. Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2003;28(12):1258-62. doi: 10.1097/01.Brs.0000065487.82469.D9 [published Online First: 2003/06/18]\u003c/li\u003e\n\u003cli\u003eUchida K, Nakajima H, Sato R, et al. Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e 2009;11(5):521-8. doi: 10.3171/2009.2.Spine08385 [published Online First: 2009/11/26]\u003c/li\u003e\n\u003cli\u003eNagoshi N, Nori S, Tsuji O, et al. Surgical and Functional Outcomes of Expansive Open-Door Laminoplasty for Patients With Mild Kyphotic Cervical Alignment. \u003cem\u003eNeurospine\u003c/em\u003e 2021;18(4):749-57. doi: 10.14245/ns.2142792.396 [published Online First: 2022/01/10]\u003c/li\u003e\n\u003cli\u003eCoe JD, Vaccaro AR, Dailey AT, et al. Lateral mass screw fixation in the cervical spine: a systematic literature review. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e 2013;95(23):2136-43. doi: 10.2106/jbjs.L.01522 [published Online First: 2013/12/07]\u003c/li\u003e\n\u003cli\u003eAbumi K, Shono Y, Taneichi H, et al. Correction of cervical kyphosis using pedicle screw fixation systems. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 1999;24(22):2389-96. doi: 10.1097/00007632-199911150-00017 [published Online First: 1999/12/10]\u003c/li\u003e\n\u003cli\u003eDuan Y, Zhang H, Min SX, et al. Posterior cervical fixation following laminectomy: a stress analysis of three techniques. \u003cem\u003eEur Spine J\u003c/em\u003e 2011;20(9):1552-9. doi: 10.1007/s00586-011-1711-z [published Online First: 2011/02/15]\u003c/li\u003e\n\u003cli\u003eAbumi K, Ito M, Sudo H. Reconstruction of the subaxial cervical spine using pedicle screw instrumentation. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2012;37(5):E349-56. doi: 10.1097/BRS.0b013e318239cf1f [published Online First: 2011/10/25]\u003c/li\u003e\n\u003cli\u003eLee S, Cho DC, Roh SW, et al. Cervical Alignment Following Posterior Cervical Fusion Surgery: Cervical Pedicle Screw Versus Lateral Mass Screw Fixation. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2021;46(10):E576-e83. doi: 10.1097/brs.0000000000003845 [published Online First: 2020/12/09]\u003c/li\u003e\n\u003cli\u003eZhou LP, Zhang ZG, Li D, et al. Robotics in Cervical Spine Surgery: Feasibility and Safety of Posterior Screw Placement. \u003cem\u003eNeurospine\u003c/em\u003e 2023;20(1):329-39. doi: 10.14245/ns.2244952.476 [published Online First: 2023/04/06]\u003c/li\u003e\n\u003cli\u003ePal D, Bayley E, Magaji SA, et al. Freehand determination of the trajectory angle for cervical lateral mass screws: how accurate is it? \u003cem\u003eEur Spine J\u003c/em\u003e 2011;20(6):972-6. doi: 10.1007/s00586-011-1694-9 [published Online First: 2011/02/01]\u003c/li\u003e\n\u003cli\u003eWu B, Liu B, Sang D, et al. The association between cervical focal kyphosis and myelopathy severity in patients with cervical spondylotic myelopathy before surgery. \u003cem\u003eEur Spine J\u003c/em\u003e 2021;30(6):1501-08. doi: 10.1007/s00586-021-06771-x [published Online First: 2021/03/01]\u003c/li\u003e\n\u003cli\u003eMahesh B, Upendra B, Vijay S, et al. Addressing Stretch Myelopathy in Multilevel Cervical Kyphosis with Posterior Surgery Using Cervical Pedicle Screws. \u003cem\u003eAsian Spine J\u003c/em\u003e 2016;10(6):1007-17. doi: 10.4184/asj.2016.10.6.1007 [published Online First: 2016/12/21]\u003c/li\u003e\n\u003cli\u003eNinomiya K, Okuyama K, Aoyama R, et al. Surgical Outcomes of Selective Laminectomy for Patients With Cervical Kyphosis: A Retrospective Study of 379 Cases. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2023;13(7):1777-86. doi: 10.1177/21925682211049799 [published Online First: 2021/11/02]\u003c/li\u003e\n\u003cli\u003eChiba K, Toyama Y, Watanabe M, et al. Impact of longitudinal distance of the cervical spine on the results of expansive open-door laminoplasty. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2000;25(22):2893-8. doi: 10.1097/00007632-200011150-00010 [published Online First: 2000/11/14]\u003c/li\u003e\n\u003cli\u003eEastlack RK, Lakomkin N, Tran S, et al. Necessity of posterior osteotomies for mild flexible cervical deformity correction. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e 2024;41(6):757-64. doi: 10.3171/2024.5.Spine231223 [published Online First: 2024/09/13]\u003c/li\u003e\n\u003cli\u003eAmes CP, Blondel B, Scheer JK, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2013;38(22 Suppl 1):S149-60. doi: 10.1097/BRS.0b013e3182a7f449 [published Online First: 2013/10/23]\u003c/li\u003e\n\u003cli\u003eYeh KT, Lee RP, Chen IH, et al. Laminoplasty instead of laminectomy as a decompression method in posterior instrumented fusion for degenerative cervical kyphosis with stenosis. \u003cem\u003eJ Orthop Surg Res\u003c/em\u003e 2015;10:138. doi: 10.1186/s13018-015-0280-y [published Online First: 2015/09/05]\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":"cervical kyphosis, laminoplasty, posterior decompression, fixation","lastPublishedDoi":"10.21203/rs.3.rs-7292535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7292535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo evaluate whether the fixation procedure is essential in posterior surgery for cervical stenosis with non-severe kyphosis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 109 patients diagnosed with cervical stenosis and non-severe kyphosis were included in this study. Patients were categorized based on the surgical approach into those who underwent laminoplasty (LP) alone and those who received fixation with either lateral mass screws (LMS) or pedicle screws (PS). Preoperative and postoperative assessments included the Visual Analog Scale (VAS) for neck pain, the modified Japanese Orthopaedic Association (mJOA) score, the Neck Disability Index (NDI), and the Short Form 36 (SF36) health survey. Sagittal parameters were measured using lateral cervical radiographs. Additionally, hospitalization data, surgical details, and complications were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNo significant differences were observed in baseline demographic characteristics among the three groups. However, the PS group had significantly longer operative duration and greater intraoperative blood loss compared to the others groups. Postoperative mJOA scores improved significantly in all groups. However, the PS group had significantly lower follow-up mJOA scores (12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9) compared to the LP (15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LMS groups (15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5, P\u0026thinsp;=\u0026thinsp;0.002). VAS scores demonstrated significant pain reduction in the PS group (preoperative 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 vs. follow-up 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8, P\u0026thinsp;=\u0026thinsp;0.046), whereas changes in the LP (-0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8, P\u0026thinsp;=\u0026thinsp;0.877) and LMS groups (-0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7, P\u0026thinsp;=\u0026thinsp;0.877) were minimal. The PS group achieved the most pronounced correction in C2-7 Cobb angle (8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u0026deg;) during surgeries. The LMS group did not achieve significant kyphosis correction, with a postoperative improvement in C2-7 Cobb angle of only 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u0026deg;, comparable to the LP group (3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.840). The overall complication rate was highest in the PS group (27.8%), followed by the LMS group (16.0%) and the LP group (9.1%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study suggests that fixation may not be essential in posterior surgery for cervical stenosis with non-severe kyphosis. Posterior surgeries without fixation were associated with shorter operative times, reduced blood loss, comparable neurological recovery and quality of life outcomes to those with fixation, as well as a lower incidence of postoperative complications.\u003c/p\u003e","manuscriptTitle":"Is Fixation Procedure Necessary in Posterior Approach Surgery for Cervical Stenosis with Non-Severe Kyphosis?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:23:24","doi":"10.21203/rs.3.rs-7292535/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":"ab75cc57-96d2-4c0c-86a1-650e687101f4","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T11:54:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:23:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7292535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7292535","identity":"rs-7292535","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}