Predictive Factors for Proximal Junctional Kyphosis in Long Fusions to the Sacrum in Adult Spinal Deformity

Maruo, Keishi; Ha, You Jung; Inoue, Shinichi; Samuel, Sumant; Okada, Eijiro; Hu, Serena S.; Deviren, Vedat; Burch, Shane; William, Schairer; Ames, Christopher P.; Mummaneni, Praveen V.; Chou, Dean; Berven, Sigurd

doi:10.1097/brs.0b013e3182a51d43

Cited by 282 publications

(252 citation statements)

References 26 publications

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“…However, extending the fusion proximally simply to prevent future PJK may lead to higher perioperative complications, pseudarthrosis, and revision surgery [14]. In our practice, we utilize shorter fusion constructs that extend to the distal thoracic spine if the desired lumbar lordosis and global balance (SVA B5 cm) can be achieved in the absence of significant thoracic kyphosis [8]. Instrumentation and fusion can be extended to the proximal thoracic spine (often T2 or T3) when there is significant thoracic scoliosis or kyphosis.…”

Section: Suggestions To Minimize Pjkmentioning

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: 94%

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Proximal junctional kyphosis following adult spinal deformity surgery

2014

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Section: Suggestions To Minimize Pjkmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 94%

Proximal junctional kyphosis following adult spinal deformity surgery

2014

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“…However, the presence of thoracic hyperkyphosis has important implications for surgical planning as it is a well-known risk factor for the development of PJK and PJF [30,42,44,46,47,49,52,55,56,69]. Therefore, in a patient with thoracic hyperkyphosis, extending the fusion and instrumentation to the upper thoracic levels is considered desirable to minimize the risk of PJK and PJF and to achieve appropriate sagittal realignment.…”

Section: Selection Of the Appropriate Level And Instrumentation For Tmentioning

confidence: 99%

“…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]. Other less well-established but likely risk factors include low bone density [44], presence of a comorbidity [33], and high body mass index [22,33].…”

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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“…4,9,10,13 Another common complication is failure to properly lordose the spine, as well as symptomatic rod fracture in the middle of the fusion constructs that is generally located at the apex of the lordotic curve in the rods. 1 The occurrence of these complications is multifactorial and includes patient selection and construct design; however, we hypothesize that an important factor may be the intraoperative loads placed on the implants during these powerful correction maneuvers and the residual load states that may be left on the implants after the procedure.…”

mentioning

confidence: 99%

Biomechanical demands on posterior fusion instrumentation during lordosis restoration procedures

Kuo

Martin

Telles³

et al. 2016

SPI

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OBJECTIVE The goal of this study was to investigate the forces placed on posterior fusion instrumentation by 3 commonly used intraoperative techniques to restore lumbar lordosis: 1) cantilever bending; 2) in situ bending; and 3) compression and/or distraction of screws along posterior fusion rods. METHODS Five cadaveric torsos were instrumented with pedicle screws at the L1–5 levels. Specimens underwent each of the 3 lordosis restoration procedures. The pedicle screw pullout force was monitored in real time via strain gauges that were mounted unilaterally at each level. The degree of correction was noted through fluoroscopic imaging. The peak loads experienced on the screws during surgery, total demand on instrumentation, and resting loads after corrective maneuvers were measured. RESULTS A mean overall lordotic correction of 10.9 ± 4.7° was achieved. No statistically significant difference in lordotic correction was observed between restoration procedures. In situ bending imparted the largest loads intraoperatively with an average of 1060 ± 599.9 N, followed by compression/distraction (971 ± 534.1 N) and cantilever bending (705 ± 413.0 N). In situ bending produced the largest total demand and postoperative loads at L-1 (1879 ± 1064.1 and 487 ± 118.8 N, respectively), which were statistically higher than cantilever bending and compression/distraction (786 ± 272.1 and 138 ± 99.2 N, respectively). CONCLUSIONS In situ bending resulted in the highest mechanical demand on posterior lumbar instrumentation, as well as the largest postoperative loads at L-1. These results suggest that the forces generated with in situ bending indicate a greater chance of intraoperative instrumentation failure and postoperative proximal pedicle screw pullout when compared with cantilever bending and/or compression/distraction options. The results are aimed at optimizing correction and fusion strategies in lordosis restoration cases.

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Predictive Factors for Proximal Junctional Kyphosis in Long Fusions to the Sacrum in Adult Spinal Deformity

Abstract: 3.

Cited by 282 publications

References 26 publications

Proximal junctional kyphosis following adult spinal deformity surgery

Proximal junctional kyphosis following adult spinal deformity surgery

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

Biomechanical demands on posterior fusion instrumentation during lordosis restoration procedures

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