Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

Kim, Hee Jin; Yagi, Mitsuru; Nyugen, Joseph; Cunningham, Matthew E.; Boachie-Adjei, Oheneba

doi:10.1007/s11999-011-2179-1

Cited by 144 publications

(74 citation statements)

References 17 publications

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“…PJK is defined as an increase in kyphosis between the caudal endplate of the uppermost instrumented vertebra (UIV) and the cephalad endplate of the vertebra 2 segments cranial to the UIV by > 10° compared to preoperative imaging. 8,10,[23][24][25] A recent systematic review reported the development of PJK in 17%-39% of patients who underwent surgery for kyphosis and/or scoliosis. 22 In contrast to many other forms of ASP, PJK has not been shown to consistently have a significant impact on HRQOL outcomes and reoperation rates 10,19,22,24,33 or have a strong correlation with preoperative sagittal imbalance.…”

Section: Discussionmentioning

confidence: 99%

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Maggio

Ailon

Smith

et al. 2015

SPI

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OBJECT The associations among global spinal alignment, patient-reported disability, and surgical outcomes have increasingly gained attention. The assessment of global spinal alignment requires standing long-cassette anteroposterior and lateral radiographs; however, spine surgeons routinely rely only on short-segment imaging when evaluating seemingly isolated lumbar pathology. This may prohibit adequate surgical planning and may predispose surgeons to not recognize associated pathology in the thoracic spine and sagittal spinopelvic malalignment. The authors used a case-based survey questionnaire to evaluate if including long-cassette radiographs led to changes to respondents' operative plans as compared with their chosen plan when cases contained standard imaging of the involved lumbar spine only. METHODS A case-based survey was distributed to AOSpine International members that consisted of 15 cases of lumbar spine pathology and lumbar imaging only. The same 15 cases were then shuffled and presented a second time with additional long-cassette radiographs. Each case required participants to select a single operative plan with 5 choices ranging from least to most extensive. The cases included 5 “control” cases with normal global spinal alignment and 10 “test” cases with significant sagittal and/or coronal malalignment. Mean scores were determined for each question with higher scores representing more invasive and/or extensive operative plans. RESULTS Of 712 spine surgeons who started the survey, 316 (44%) completed the entire series, including 68% of surgeons with spine fellowship training and representation from more than 40 countries. For test cases, but not for control cases, there were significantly higher average surgical invasiveness scores for cases presented with long-cassette radiographs (4.2) as compared with those cases with lumbar imaging only (3.4; p = 0.002). The addition of long-cassette radiographs resulted in 82.1% of respondents recommending instrumentation up to the thoracic spine, a 23.2% increase as compared with the same cases presented with lumbar imaging only (p = 0.008). CONCLUSIONS This study demonstrates the importance of maintaining a low threshold for performing standing long-cassette imaging when assessing seemingly isolated lumbar pathology. Such imaging is necessary for the assessment of spinopelvic and global spinal alignment, which can be important in operative planning. Deformity, particularly positive sagittal malalignment, may go undetected unless one maintains a high index of suspicion and obtains long-cassette radiographs. It is recommended that spine surgeons recognize the prevalence and importance of such deformity when contemplating operative intervention.

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Section: Discussionmentioning

confidence: 99%

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Maggio

Ailon

Smith

et al. 2015

SPI

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“…4,7,[9][10][11]23 It has been associated with a posterior more than an anterior spinal fusion. 8,20 Preserving the posterior soft tissue and ligamentous structure may be useful as a surgical strategy to prevent PJK.…”

Section: Discussionmentioning

confidence: 99%

“…7,10,12 Risk factors contributing to this flexion deformity include end vertebrae selection, facet violation proximal to the upper instrumented vertebrae, weakened structural support due to significant soft tissue disruption, extensive junctional paraspinal musculature dissection, and loss of integrity of the posterior tension band. 4,7,[9][10][11]21,23 Fixed motion segments after spinal instrumentation and fusion may increase the stress on adjacent unfused spinal segments and cause accelerated degeneration of the adjacent segments. 2,18 The significant stress gradient between the instrumented and noninstrumented spine can result in higher stress concentration at the transition and the development of PJK.…”

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confidence: 99%

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Maruo

Racine

et al. 2013

SPI

141

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Object Proximal junctional kyphosis (PJK) is a common and significant complication after corrective spinal deformity surgery. The object of this study was to compare—based on clinical outcomes, postoperative proximal junctional kyphosis rates, and prevalence of revision surgery—proximal thoracic (PT) and distal thoracic (DT) upper instrumented vertebra (UIV) in adults who underwent spine fusion to the sacrum for the treatment of spinal deformity. Methods In this retrospective study the authors evaluated clinical and radiographic data from consecutive adults (age > 21 years) with a deformity treated using long instrumented posterior spinal fusion to the sacrum in the period from 2007 to 2009. The PT group included patients in whom the UIV was between T-2 and T-5, whereas the DT group included patients in whom the UIV level was between T-9 and L-1. Perioperative surgical data were compared between the PT and DT groups. Additionally, segmental, regional, and global spinal alignments, as well as the sagittal Cobb angle at the proximal junction, were analyzed on preoperative, early postoperative, and final standing 36-in. radiographs. Patient-reported outcome measurements (visual analog scale, Scoliosis Research Society Patient Questionnaire-22, Oswestry Disability Index, and the 36-Item Short-Form Health Survey) were compared. Results Eighty-nine patients, 22 males and 67 females, had a minimum follow-up of 2 years, and thus were eligible for participation in this study. Sixty-seven patients were in the DT group and 22 were in the PT group. Operative time (p = 0.387) and estimated blood loss (p < 0.05) were slightly higher in the PT group. The overall rate of revision surgery was 48.0% and 54.5% in the DT and PT groups, respectively (p = 0.629). The prevalence of PJK according to radiological criteria was 34% in the DT group and 27% in the PT group (p = 0.609). The percent of patients with PJK that required surgical correction (surgical PJK) was 11.9% (8 of 67) in the DT group and 9.1% (2 of 22) in the PT group (p = 1.0). The onset of surgical PJK was significantly earlier than radiological PJK in the DT group (p < 0.01). The types of PJK were different in the PT and DT groups. Compression fracture at the UIV was more prevalent in the DT group, whereas subluxation was more prevalent in the PT group. Postoperatively, the PT group had less thoracic kyphosis (p = 0.02), less sagittal imbalance (p < 0.01), and less pelvic tilt (p = 0.04). In the DT group, early postoperative radiographs demonstrated that the proximal junctional angle of patients with surgical PJK was greater than in those without PJK and those with radiological PJK (p < 0.01). Clinical outcomes were significantly improved in both groups, and there was no significant difference between the groups. Conclusions Both PT and DT UIVs improve segmental and global sagittal plane alignment as well as patient-reported quality of life in those treated for adult spinal deformity. The prevalence of PJK was not different in the PT and DT groups. However, compression fracture was the mechanism more frequently observed with DT PJK, and subluxation was the mechanism more frequently observed in PT PJK. Strategies to avoid PJK may include vertebral augmentation to prevent fracture at the DT spine and mechanical means to prevent vertebral subluxation at the PT spine.

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“…However, several major risk factors for PJK and PJF have been described. The potentially modifiable risk factors include greater curvature correction [30,33,[45][46][47][48][49], combined anterior-posterior spinal fusion [19,33,42,44,50,51], fusion to the sacro-pelvis [30, 34, 40-42, 44, 52], and residual sagittal imbalance [53]. Nonmodifiable factors with clear correlation to PJK development include the following: older age (>55 years) [19,22,33,45] and severe pre-operative sagittal imbalance [30,42,44,46,49,52,[54][55][56].…”

Section: Risk Factorsmentioning

confidence: 99%

Proximal junctional kyphosis and failure—diagnosis, prevention, and treatment

Nguyễn

Kong

Hart

2016

Curr Rev Musculoskelet Med

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Technical advancements have enabled the spinal deformity surgeon to correct severe spinal mal-alignment. However, proximal adjacent segment pathology (ASP) remains a significant issue. Examples include proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). Agreement on the definition, classification, and pathophysiology of PJK and PJF remains incomplete, and an understanding of the risk factors, means of prevention, and treatment of this problem remains to be elucidated. In general, PJK is a relatively asymptomatic radiographic diagnosis managed with patient reassurance and monitoring. On the other hand, PJF is characterized by mechanical instability, pain, and more severe kyphosis, with potential for neurologic compromise. Patients who develop PJF more often require revision surgery than those with PJK. This chapter will review the current understanding of PJK and PJF.

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Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

Cited by 144 publications

References 17 publications

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Proximal junctional kyphosis and failure—diagnosis, prevention, and treatment

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