Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction

Mikula, Anthony L.; Fogelson, Jeremy L.; Lakomkin, Nikita; Flanigan, Patrick M.; Pinter, Zachariah; Doan, Matthew K.; Bydon, Mohamad; Nassr, Ahmad; Freedman, Brett A.; Sebastian, Arjun S.; Abode-Iyamah, Kingsley; Anderson, Paul A.; Elder, Benjamin D.

doi:10.1093/ons/opab236

Cited by 20 publications

(21 citation statements)

References 35 publications

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“…This finding is consistent with previous studies showing low bone density as a risk factor of PJF. 19,20 Based on our review, patients with a Chance-type proximal junctional fracture generally have (1) an increase in PJA (kyphosis), (2) cephalocaudal widening of the UIV pedicles, and (3) possible anterior column compression deformity of the UIV. These findings, in the setting of a patient with persistent or new pain symptoms, should prompt the surgeon to order a CT scan to confirm the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Chance Fracture Pattern Presenting in Proximal Junctional Failure

et al. 2023

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Introduction: We present a case series of proximal junctional failure due to a Chance-type fracture. Methods: This is a retrospective review of patients who developed proximal junctional kyphosis because of Chance-type proximal junctional failure after spinal fusion for adult spinal deformity. Results: Fifteen patients were identified (4M:11F). The average age was 61.4 years (range, 39 to 77). The mean time to fracture identification was 25.4 days (range, 3 to 65). The average number of levels instrumented was 6.7 (range, 2 to 17). No patients had antecedent trauma before fracture onset. In 67% of cases with a lumbar upper instrumented vertebra (UIV), there was overcorrection of lumbar lordosis (LL) and/or lower LL. The five cases with a lower thoracic UIV had undergone notable correction of preoperative thoracolumbar junction kyphosis. 14 of 15 patients were treated with extension of fusion. Pedicle screws at the fracture level were salvaged by changing to an anatomic trajectory. Conclusion: Continued pain at 6 to 12 weeks with radiographs showing an increased proximal junctional angle and cephalocaudal pedicle widening at the UIV should raise suspicion for this unique fracture pattern. A CT scan is recommended. Low bone density, LL and/or lower LL overcorrection, and selection of lower thoracic UIV in the setting of notable thoracolumbar junction correction may contribute to fracture risk.

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Section: Discussionmentioning

confidence: 99%

Chance Fracture Pattern Presenting in Proximal Junctional Failure

et al. 2023

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“…Complications at the proximal junction of long thoracolumbar and lumbar fusion constructs are both common and burdensome to patients and health care systems 1,4. In an effort to reduce the risk of PJK and PJF, many studies have sought to identify risk factors for the development of these complications 1,5–9. In their study of patients undergoing thoracolumbar fusions that terminated proximally near the thoracolumbar junction for degenerative indications, Mikula et al 7 identified diminished HU at the UIV as a risk factor for PJK.…”

Section: Discussionmentioning

confidence: 99%

“…1,4 In an effort to reduce the risk of PJK and PJF, many studies have sought to identify risk factors for the development of these complications. 1,[5][6][7][8][9] In their study of patients undergoing thoracolumbar fusions that terminated proximally near the thoracolumbar junction for degenerative indications, Mikula et al 7 identified diminished HU at the UIV as a risk factor for PJK. A subsequent study by the same authors revealed that lower HU at the UIV was also associated with an increased risk of PJK and PJF in patients undergoing long-construct thoracolumbar fusions that terminated proximally in the upper thoracic spine.…”

Section: Discussionmentioning

confidence: 99%

“…1,4 Many risk factors for the development of PJK and PJF have been proposed, including elevated body mass index (BMI), poor postoperative sagittal balance, older age, construct extension caudally to the pelvis, low bone mineral density (BMD) on dual-energy x-ray absorptiometry (DEXA), and low Hounsfield Units (HU) at the upper instrumented vertebra (UIV). 1,[5][6][7][8][9] Given the clinical impact of PJK and PJF, the search for modifiable risk factors and surgical techniques to decrease the likelihood of these complications continues. 4,6,[10][11][12][13] Sarcopenia is the progressive loss of skeletal muscle mass and is a manifestation of frailty that is not accounted for by other risk stratification methods.…”

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confidence: 99%

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Lower Hounsfield Units and Severe Multifidus Sarcopenia Are Independent Predictors of Increased Risk for Proximal Junctional Kyphosis and Failure Following Thoracolumbar Fusion

Pinter

Mikula

Townsley

et al. 2022

Spine

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Study Design. Retrospective cohort study.Objective. The purpose of the present study was to assess the impact of sarcopenia on the development of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following thoracolumbar spine fusion surgery using opportunistic evaluation of paraspinal fatty degeneration on preoperative magnetic resonance imaging. Summary of Background Data. While paraspinal sarcopenia has been shown to have detrimental consequences following posterior cervicothoracic fusions, the impact of paraspinal sarcopenia on PJK and PJF following thoracolumbar spine fusion surgery remains unknown. Materials and Methods. We performed a retrospective review of patients who underwent posterior spine fusion surgery that extended caudally to the pelvis and terminated cranially between T10 and L2 between 2010 and 2017. The cohort was divided into three groups: (1) patients without PJK or PJF, (2) patients with PJK but no PJF, and (3) patients with PJF. Univariate and multivariate analyses were performed to determine risk factors for the development of proximal junctional complications. Results. We identified 150 patients for inclusion in this study. Mean Hounsfield Units at the upper instrumented vertebra (UIV) was 148.3 ± 34.5 in the cohort of patients without PJK or PJF, which was substantially higher than values recorded in the PJK (117.8 ± 41.9) and PJF (118.8 ± 41.8) subgroups (P < 0.001). Severe multifidus sarcopenia was identified at a much higher rate in the subgroups of patients who developed PJK (76.0%) and PJF (78.9%) than in the subgroup of patients who developed neither PJK nor PJF (34.0%; P < 0.001). Multivariate analysis demonstrated both low HU at the UIV and moderate-severe multifidus sarcopenia to be risk factors for the development of PJK and PJF. Conclusion. The results of this study suggest severe paraspinal sarcopenia and diminished bone density at the UIV impart an increased risk of developing PJK and PJF, while markers of systemic frailty such as modified Frailty Index and Charlson Comorbidity Index are not associated with an increased risk of these complications.

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“…Various other articles report higher PJF rates in patients with low-normal bone mineral density receiving no teriparatide treatment (range: 19%-28%). [19][20][21] To create a conservative model, we chose a PJF probability of 15% in the nonteriparatide group. Finally, of the patients who underwent revision for PJF, the probability of having a poor outcome and requiring a second reoperation was assumed to be 16% ( 10%) based on previously published studies.…”

Section: Probability Estimatesmentioning

confidence: 99%

Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery

Raad

Ortiz-Babilonia

Hassanzadeh

et al. 2022

Spine

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Study Design. A cost-utility analysis study. Objective. This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery. Summary of Background Data. There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established. Materials and Methods. A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia (T score <−1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model. Results. Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF. Conclusions. Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.

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Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction

Cited by 20 publications

References 35 publications

Chance Fracture Pattern Presenting in Proximal Junctional Failure

Chance Fracture Pattern Presenting in Proximal Junctional Failure

Lower Hounsfield Units and Severe Multifidus Sarcopenia Are Independent Predictors of Increased Risk for Proximal Junctional Kyphosis and Failure Following Thoracolumbar Fusion

Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery

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