How do C2 tilt and C2 slope correlate with patient reported outcomes in patients after anterior cervical discectomy and fusion?

Srikanth N. Divi*, Wesley H. Bronson, Jose A. Canseco, Michael Chang, Dhruv K.C. Goyal, Kristen J. Nicholson, Victor E. Mujica, Ian David Kaye, Mark F. Kurd, Barrett I. Woods, Kristen E. Radcliff, Jeffrey A. Rihn, David Greg Anderson, Alan S. Hilibrand, Christopher K. Kepler, Alexander R. Vaccaro, Gregory D. Schroeder

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


BACKGROUND/CONTEXT: C2 tilt and C2 slope are quick and easy measurements to obtain on lateral radiographs and may be used to determine overall cervical sagittal alignment; however, the influence of these measurements on patient outcomes has not been well established in literature. PURPOSE: To determine if C2 tilt and/or C2 slope predict patient outcomes better compared with conventional radiographic measures after an anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 249 patients who underwent 1 to 3 level ACDF to address radiculopathy and/or myelopathy at a single academic institution between 2011 and 2015 were identified. Patients with less than 1 year of follow-up were excluded. OUTCOME MEASURES: Patient Reported Outcomes: Neck Disability Index (NDI), Physical Component Score-12 (PCS-12), and Mental Component Score (MCS-12), Visual Analog Score (VAS) Neck and Arm scores Cervical radiographic measurements: C2 tilt, C2 slope, C2–C7 lordosis, cervical SVA, T1 slope, T1 slope minus cervical lordosis (TS-CL), and C2–C7 ROM METHODS: Pearson correlation tests were performed to assess for significant associations between radiographic measurements and patient outcomes. Multiple linear regression models were developed adjusting for demographics and radiographic parameters to determine which factors were predictive of patient outcomes. RESULTS: C2 tilt and TS-CL correlated with all postoperative physical outcome scores (NDI, PCS-12, VAS Neck and ARM; p<.05), however no association was seen between C2 slope and postoperative outcomes. After accounting for the presence of subaxial deformity, C2 tilt and TS-CL remained strongly correlated to patient outcome scores. With multiple linear regression, C2 tilt was a significant predictor for NDI, whereas TS-CL was a significant predictor for PCS-12, VAS Neck and VAS Arm. CONCLUSIONS: C2 tilt significantly correlated with well-described conventional cervical parameters as well as postoperative physical outcomes measures, especially NDI, on multivariate analysis. C2 tilt may provide an easy and practical tool for predicting physical outcomes after ACDF.

Original languageEnglish (US)
Pages (from-to)578-585
Number of pages8
JournalSpine Journal
Issue number4
StatePublished - Apr 2021


  • ACDF
  • C2 slope
  • C2 tilt
  • MCS-12
  • NDI
  • PCS-12
  • VAS arm
  • VAS neck

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Clinical Neurology


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