Different Risk Factors of Proximal Junctional Kyphosis and Proximal Junctional Failure Following Long Instrumented Fusion to the Sacrum for Adult Spinal Deformity: Survivorship Analysis of 160 Patients

Park, Se-Jun; Lee, Chong-Suh; Chung, Sung-Soo; Lee, Jun-Young; Kang, Sang-Soo; Park, Se-Hwan

doi:10.1227/neu.0000000000001240

Cited by 148 publications

(114 citation statements)

References 29 publications

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“…While our results probably underestimated the true 2-year PJK rate, it is also well documented that the majority of PJK happens within the first few months following the surgical procedure. 13,28,37…”

Section: Discussionmentioning

confidence: 99%

Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Lafage

Obeid

Liabaud

et al. 2019

Journal of Neurosurgery: Spine

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OBJECTIVEThe surgical correction of adult spinal deformity (ASD) often involves modifying lumbar lordosis (LL) to restore ideal sagittal alignment. However, corrections that include large changes in LL increase the risk for development of proximal junctional kyphosis (PJK). Little is known about the impact of cranial versus caudal correction in the lumbar spine on the occurrence of PJK. The goal of this study was to investigate the impact of the location of the correction on acute PJK development.METHODSThis study was a retrospective review of a prospective multicenter database. Surgically treated ASD patients with early follow-up evaluations (6 weeks) and fusions of the full lumbosacral spine were included. Radiographic parameters analyzed included the classic spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], PI−LL, and sagittal vertical axis [SVA]) and segmental correction. Using Glattes’ criteria, patients were stratified into PJK and noPJK groups and propensity matched by age and regional lumbar correction (ΔPI−LL). Radiographic parameters and segmental correction were compared between PJK and noPJK patients using independent t-tests.RESULTSAfter propensity matching, 312 of 483 patients were included in the analysis (mean age 64 years, 76% women, 40% with PJK). There were no significant differences between PJK and noPJK patients at baseline or postoperatively, or between changes in alignment, with the exception of thoracic kyphosis (TK) and ΔTK. PJK patients had a decrease in segmental lordosis at L4-L5-S1 (−0.6° vs 1.6°, p = 0.025), and larger increases in segmental correction at cranial levels L1-L2-L3 (9.9° vs 7.1°), T12-L1-L2 (7.3° vs 5.4°), and T11-T12-L1 (2.9° vs 0.7°) (all p < 0.05).CONCLUSIONSAlthough achievement of an optimal sagittal alignment is the goal of realignment surgery, dramatic lumbar corrections appear to increase the risk of PJK. This study was the first to demonstrate that patients who developed PJK underwent kyphotic changes in the L4–S1 segments while restoring LL at more cranial levels (T12–L3). These findings suggest that restoring lordosis at lower lumbar levels may result in a decreased risk of developing PJK.

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Section: Discussionmentioning

confidence: 99%

Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Lafage

Obeid

Liabaud

et al. 2019

Journal of Neurosurgery: Spine

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“…In yet another study, Ghiselli et al 24 found that patients who underwent a 1-level fusion were more likely to develop clinical ASD than those who underwent a multilevel fusion. 52 Similarly, Hilibrand et al 29 found more incidences of ASD after 1-level cervical fusions than after multilevel arthrodesis. Given the aforementioned controversies, further study is required.…”

Section: Discussionmentioning

confidence: 96%

“…Previous studies found increased rates of ASD, specifically PJK, in patients who underwent surgical correction and had a higher preoperative SVA. 52 In our subset analysis, the majority of patients had a normal preoperative SVA (as measured on standing 36-inch plain scoliosis radiographs) ( Table 1). Although a limitation in our study is that upright scoliosis radiographs to use for the determination of perioperative SVA were not available for all patients, normal preoperative SVA parameters and mild SVA changes might have contributed to our low rate of ASD and reoperation.…”

Section: Discussionmentioning

confidence: 99%

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Adjacent-segment disease after thoracic pedicle screw fixation

Agarwal

Heary

Agarwal

2018

Journal of Neurosurgery: Spine

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OBJECTIVEPedicle screw fixation is a technique widely used to treat conditions ranging from spine deformity to fracture stabilization. Pedicle screws have been used traditionally in the lumbar spine; however, they are now being used with increasing frequency in the thoracic spine as a more favorable alternative to hooks, wires, or cables. Although safety concerns, such as the incidence of adjacent-segment disease (ASD) after cervical and lumbar fusions, have been reported, such issues in the thoracic spine have yet to be addressed thoroughly. Here, the authors review the literature on ASD after thoracic pedicle screw fixation and report their own experience specifically involving the use of pedicle screws in the thoracic spine.METHODSSelect references from online databases, such as PubMed (provided by the US National Library of Medicine at the National Institutes of Health), were used to survey the literature concerning ASD after thoracic pedicle screw fixation. To include the authors’ experience at Rutgers New Jersey Medical School, a retrospective review of a prospectively maintained database was performed to determine the incidence of complications over a 13-year period in 123 consecutive adult patients who underwent thoracic pedicle screw fixation. Children, pregnant or lactating women, and prisoners were excluded from the review. By comparing preoperative and postoperative radiographic images, the occurrence of thoracic ASD and disease within the surgical construct was determined.RESULTSDefinitive radiographic fusion was detected in 115 (93.5%) patients. Seven incidences of instrumentation failure and 8 lucencies surrounding the screws were observed. One patient was observed to have ASD of the thoracic spine. The mean follow-up duration was 50 months.CONCLUSIONSThis long-term radiographic evaluation revealed the use of pedicle screws for thoracic fixation to be an effective stabilization modality. In particular, ASD seems to be less of a problem in the relatively immobile thoracic spine than in the more mobile cervical and lumbar spines.

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“…Most instances of PJK occur within 3 months of surgery. 2,4,5 There are surgical, radiographic, and patient-specific risk factors that may lead to the development of PJK. 2,3,[6][7][8][9][10] Fracture at the upper instrumented vertebrae is the most common mechanism for the development of PJK.…”

Section: Introductionmentioning

confidence: 99%

Transpedicular-Transdiscal Cement Augmentation Treatment of Thoracolumbar Fusion Proximal Junctional Failure

et al. 2019

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Background: Long instrumented fusions for adult deformity have a proximal junction kyphosis rate between 20% and 40%. When symptomatic, proximal junctional failure (PJF) often requires revision surgery and is associated with significant morbidity. Vertebral cement augmentation (VCA) has been used for prophylaxis against PJF but has not been previously described as treatment after onset of PJF has occurred. We describe a series of patients with PJF of long posterior spinal fusions that were treated at our institution using a novel VCA technique. Methods: Three patients with PJF above thoracolumbopelvic fusions were retrospectively reviewed following treatment with transpedicular-transdiscal VCA. The medical record was reviewed for demographic data, outcomes scores, and radiographic images. Results: Mean age was 69.3 years. Mean follow-up was 13.3 months. Mean preprocedure visual analog scale score was 8.67, and postprocedure visual analog scale score was 4.00. Mean preprocedure sagittal balance was 9.7 cm, and postprocedure sagittal balance was 5.8 cm. No patients required revision surgery for PJF in the follow-up period. Conclusions: Transpedicular-transdiscal VCA treatment for PJF is safe and may have the potential to prevent the need for revision surgery. Level of Evidence: 4.

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Different Risk Factors of Proximal Junctional Kyphosis and Proximal Junctional Failure Following Long Instrumented Fusion to the Sacrum for Adult Spinal Deformity: Survivorship Analysis of 160 Patients

Cited by 148 publications

References 29 publications

Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Adjacent-segment disease after thoracic pedicle screw fixation

Transpedicular-Transdiscal Cement Augmentation Treatment of Thoracolumbar Fusion Proximal Junctional Failure

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