Incidence, Mode, and Location of Acute Proximal Junctional Failures After Surgical Treatment of Adult Spinal Deformity

Hostin, Richard A.; McCarthy, Ian; O’Brien, Michael F.; Bess, Shay; Line, Breton; Boachie-Adjei, Oheneba; Burton, Doug; Gupta, Munish C.; Ames, Christopher P.; Deviren, Vedat; Kebaish, Khaled M.; Shaffrey, Christopher I.; Wood, Kirkham B.; Hart, Robert A.

doi:10.1097/brs.0b013e318271319c

Cited by 248 publications

(196 citation statements)

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“…In a large multi-center, retrospective study consisting of adult deformity patients, Hostin et al [2] defined PJK as the Cobb angle formed by the lower endplate of the UIV and the upper endplate of two supra-adjacent vertebrae above the UIV 15°or greater. O'Shaughnessy et al [14] and Bridwell et al [15] used 20°as their cutoff value.…”

Section: Definitionmentioning

confidence: 99%

“…In contrast, symptomatic PJK is frequently encountered in children with early onset scoliosis who undergo fusionless surgery (e.g., growing rod), often necessitating revision surgery. In addition to the disc change, PJK in adults also includes fractures, subluxations, and long sweeping kyphosis above the fusion [1][2][3][4][5][6][7][8]. This can lead to proximal junction failure causing pain, deformity, instability, and implant prominence, with a risk of neurological deficit.…”

Section: Introductionmentioning

confidence: 95%

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Proximal junctional kyphosis following adult spinal deformity surgery

2014

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Section: Definitionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 95%

Proximal junctional kyphosis following adult spinal deformity surgery

2014

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“…22,24 However, a subset of PJK, known as "proximal junctional failure" (PJF), has recently been identified as a more severe form of PJK that is associated with an increased need for revision surgery. 4,15,16,18,35,47,48,51 PJF is defined as a > 10° change of kyphosis between the UIV and the vertebra 2 levels above the UIV (UIV+2), along with a fracture in the vertebral body of UIV or UIV+1 and/or a disruption of the posterior osseoligamentous complex and/or pullout of instrumentation at the UIV. 4,15,16,18,35,47,48,51 Even though both PJK and PJF are defined, at least partly, by an increased proximal kyphosis, PJF is thought to represent an entity distinct from PJK with differing pathology and risk factors.…”

Section: Discussionmentioning

confidence: 99%

“…4,15,16,18,35,47,48,51 PJF is defined as a > 10° change of kyphosis between the UIV and the vertebra 2 levels above the UIV (UIV+2), along with a fracture in the vertebral body of UIV or UIV+1 and/or a disruption of the posterior osseoligamentous complex and/or pullout of instrumentation at the UIV. 4,15,16,18,35,47,48,51 Even though both PJK and PJF are defined, at least partly, by an increased proximal kyphosis, PJF is thought to represent an entity distinct from PJK with differing pathology and risk factors. Specifically, PJF appears to result from an acute event rather than from a recurrent deformity 15,48 and has been shown to have a strong association with preoperative spinopelvic mismatch, increased SVA, and increased thoracic kyphosis.…”

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

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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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“…Hostin et al reported a 5.6% incidence of acute PJK. 12 An advantage of fusion to the UT spine is that the UT segments surrounded by the rib cage and the scapulae are the most stabilized segments in the thoracic spine. 8 However, our data suggest that the stress caused by the deformity correction was distributed over fewer motion segments (only in the cervicothoracic spine) in the UT group than in the LT group (in the thoracic spine and cervicothoracic spine).…”

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confidence: 99%

Long fusion from sacrum to thoracic spine for adult spinal deformity with sagittal imbalance: upper versus lower thoracic spine as site of upper instrumented vertebra

Fujimori

Inoue

et al. 2014

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Object Despite increasing numbers of patients with adult spinal deformity, it is unclear how to select the optimal upper instrumented vertebra (UIV) in long fusion surgery for these patients. The purpose of this study was to compare the use of vertebrae in the upper thoracic (UT) versus lower thoracic (LT) spine as the upper instrumented vertebra in long fusion surgery for adult spinal deformity. Methods Patients who underwent fusion from the sacrum to the thoracic spine for adult spinal deformity with sagittal imbalance at a single medical center were studied. The patients with a sagittal vertical axis (SVA) ≥ 40 mm who had radiographs and completed the 12-item Short-Form Health Survey (SF-12) preoperatively and at final follow-up (≥ 2 years postoperatively) were included. Results Eighty patients (mean age of 61.1 ± 10.9 years; 69 women and 11 men) met the inclusion criteria. There were 31 patients in the UT group and 49 patients in the LT group. The mean follow-up period was 3.6 ± 1.6 years. The physical component summary (PCS) score of the SF-12 significantly improved from the preoperative assessment to final follow-up in each group (UT, 34 to 41; LT, 29 to 37; p = 0.001). This improvement reached the minimum clinically important difference in both groups. There was no significant difference in PCS score improvement between the 2 groups (p = 0.8). The UT group had significantly greater preoperative lumbar lordosis (28° vs 18°, p = 0.03) and greater thoracic kyphosis (36° vs 18°, p = 0.001). After surgery, there was no significant difference in lumbar lordosis or thoracic kyphosis. The UT group had significantly greater postoperative cervicothoracic kyphosis (20° vs 11°, p = 0.009). The UT group tended to maintain a smaller positive SVA (51 vs 73 mm, p = 0.08) and smaller T-1 spinopelvic inclination (−2.6° vs 0.6°, p = 0.06). The LT group tended to have more proximal junctional kyphosis (PJK), although the difference did not reach statistical significance. Radiographic PJK was 32% in the UT group and 41% in the LT group (p = 0.4). Surgical PJK was 6.4% in the UT group and 10% in the LT group (p = 0.6). Conclusions Both the UT and LT groups demonstrated significant improvement in clinical and radiographic outcomes. A significant difference was not observed in improvement of clinical outcomes between the 2 groups.

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Incidence, Mode, and Location of Acute Proximal Junctional Failures After Surgical Treatment of Adult Spinal Deformity

Cited by 248 publications

References 13 publications

Proximal junctional kyphosis following adult spinal deformity surgery

Proximal junctional kyphosis following adult spinal deformity surgery

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

Long fusion from sacrum to thoracic spine for adult spinal deformity with sagittal imbalance: upper versus lower thoracic spine as site of upper instrumented vertebra

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