Predictive model for distal junctional kyphosis after cervical deformity surgery

Passias, Peter G.; Vasquez-Montes, Dennis; Poorman, Gregory W.; Protopsaltis, Themistocles S.; Horn, Samantha R.; Bortz, Cole; Segreto, Frank A.; Diebo, Bassel G.; Ames, Christopher P.; Smith, Justin S.; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric O.; Shaffrey, Chris; Bess, Shay; Schwab, Frank J.

doi:10.1016/j.spinee.2018.04.017

Cited by 69 publications

(111 citation statements)

References 17 publications

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“…The current study is one of the largest to focus on the surgical treatment of rigid CK and includes a multitude of etiologies. Sample characteristics regarding age, ASA-score, fusion levels, blood loss, and use of anterior and/or posterior and combined approaches were similar to previous studies on CK with a representative sample [1,23,[27][28][29][30][31]. Our study was designed to address all facets of treating rigid CK and serves as a good basis to characterize future research needs.…”

Section: Complicationsmentioning

confidence: 90%

“…With residual imbalance, there is a significantly increased risk of construct failure, delayed union, and loss of correction [75,[80][81][82][83][84]. In a study on 71 patients with cervical deformity [29,81], a multivariate regression analysis revealed that the occurrence of post-operative DJK was the only significant parameter associated with suboptimal outcomes in respect to correction of C2-C7 SVA. A larger thoracic inclination (T1-slope) was related to significantly increased rates of DJK (29% vs. 1%).…”

Section: Complicationsmentioning

confidence: 99%

“…A larger thoracic inclination (T1-slope) was related to significantly increased rates of DJK (29% vs. 1%). In another analysis [29] on 101 patients, 24% of patients met criteria for DJK and 6% needed revision surgery. Baseline radiographic parameters were identified as strongest predictors for DJK.…”

Section: Complicationsmentioning

confidence: 99%

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Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project

et al. 2018

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Introduction and purpose Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. Methods Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types AD). Results Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). Conclusions Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.

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Section: Complicationsmentioning

confidence: 90%

Section: Complicationsmentioning

confidence: 99%

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Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project

et al. 2018

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“…One recent study of surgical CD patients demonstrated that both cervical and global radiographic parameters were predictive of the postoperative complication of distal junctional kyphosis in the CD cohort. 15 Other studies have also shown that global alignment affects the cervical spine and that in a thoracolumbar deformity population, both cervical and global sagittal alignment parameters are predictive of worse CD. 13,14 Additionally, the predictor showed that having more than 9 vertebral levels in the preoperative maximal…”

Section: Discussionmentioning

confidence: 96%

Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery

Horn

Passias

et al. 2020

Journal of Neurosurgery: Spine

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OBJECTIVECervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.METHODSThe authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).RESULTSIn total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).CONCLUSIONSOf all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.

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“…There is no golden standard for measuring cervical sagittal malalignment. We, and many others [11], used the C2-C7 Cobb angle as we believe it to be a reliable quantification of overall global cervical alignment that does not overlook distal junctional kyphosis [25]. However, other measurements of cervical sagittal malalignment exist, for example T1 slope, sagittal vertical axis, chin-brow vertical angle, and Cobb angle with the surgical area as end points [11,15,26].…”

Section: Limitationsmentioning

confidence: 99%

Incidence and predictors of kyphotic deformity following resection of cervical intradural tumors in adults: a population-based cohort study

et al. 2020

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Background The first line of treatment for most cervical intradural tumors is surgical resection through laminotomy or laminectomy. This may cause a loss of posterior pulling force leading to kyphosis, which is associated with decreased functional outcome. However, the incidence and predictors of kyphosis in these patients are poorly understood. Object To assess the incidence of posterior fixation (PF), as well as predictors of radiological kyphosis, following resection of cervical intradural tumors in adults. Methods A population-based cohort study was conducted on adult patients who underwent intradural tumor resection via cervical laminectomy with or without laminoplasty between 2005 and 2017. Primary outcome was kyphosis requiring PF. Secondary outcome was radiological kyphotic increase, measured by the change in the C2–C7 Cobb angle between pre- and postoperative magnetic resonance images. Results Eighty-four patients were included. Twenty-four percent of the tumors were intramedullary, and the most common diagnosis was meningioma. The mean laminectomy range was 2.4 levels, and laminoplasty was performed in 40% of cases. No prophylactic PF was performed. During a mean follow-up of 4.4 years, two patients (2.4%) required delayed PF. The mean radiological kyphotic increase after surgery was 3.0°, which was significantly associated with laminectomy of C2 and C3. Of these, C3 laminectomy demonstrated independent risk association. Conclusions There was a low incidence of delayed PF following cervical intradural tumor resection, supporting the practice of not performing prophylactic PF. Kyphotic increase was associated with C2 and C3 laminectomy, which could help identify at-risk patients were targeted follow-up is indicated.

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Predictive model for distal junctional kyphosis after cervical deformity surgery

Cited by 69 publications

References 17 publications

Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project

Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project

Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery

Incidence and predictors of kyphotic deformity following resection of cervical intradural tumors in adults: a population-based cohort study

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