Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long-segment fusion for adult spinal deformity

Ghobrial, George M.; Eichberg, Daniel G.; Kolcun, John Paul G.; Madhavan, Karthik; Lebwohl, Nathan H.; Green, Barth A.; Gjolaj, Joseph P.

doi:10.1016/j.spinee.2017.05.015

Cited by 70 publications

(63 citation statements)

References 46 publications

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“…Evidence in the literature examining techniques to prevent PJK is sparse but actively growing. 11 , 17 , 21 , 27 - 29 Many investigators have examined the relationship between construct stiffness and PJK. Biomechanical studies have identified implants that reduce the stiffness of the proximal construct 14 in hopes that one may reduce PJK in a clinical setting.…”

Section: Discussionmentioning

confidence: 99%

“…9 Other strategies to reduce PJK include cement augmentation at or above the upper instrumented vertebrae (UIV) and a "soft landing" at the top of the construct. [10][11][12][13][14][15][16][17] None of these approaches, however, address the posterior ligamentous structures (PLS) at the UIV. The role of the PLS in the stability of the proximal motion segments has been well established in several biomechanical models.…”

Section: Introductionmentioning

confidence: 99%

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Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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Study Design: Retrospective cohort study.Objectives: Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year. Methods: A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIVÀ1 with a surgical nylon tape while PLSÀ patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts. Results: A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLSÀ (28.6%) were similar (P ¼ .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P ¼ .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK. Conclusion: Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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“…However, limited to teriparatide, the drug was more frequently used in group B, although the difference was not significant. To prevent uppermost PS loosening early after surgery, pre- and postoperative treatment with teriparatide or certain PS augmentation such as polymethylmethacrylate cement injection and/or expandable PS may be necessary [ 1 , 6 , 18 ].…”

Section: Discussionmentioning

confidence: 99%

“…The rates of revision surgery due to proximal junctional kyphosis/failure (PJK/PJF) following correction and fusion surgery for adult spinal deformity (ASD) is high, and its risk assessment and countermeasures are necessary but still insufficient [ 1 – 7 ]. The potentially modifiable risk factors are greater curvature correction, combined anterior-posterior spinal fusion, hybrid instrumentation (proximal hooks and distal pedicle screws), fusion to the sacro-pelvis, thoracoplasty procedure, and residual sagittal imbalance [ 4 , 5 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study

et al. 2018

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BackgroundProximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery in elderly patients is markedly influenced by osteoporosis causing additional vertebral fracture and loosening of pedicle screws (PS). This study aimed to investigate the association between mean bone density represented in Hounsfield units (HU) on spinal computed tomography (CT) and revision surgery for PJK or postoperative additional vertebral fracture following ASD surgery in elderly patients.MethodsThe subjects were 54 ASD patients aged 65 years or older who were treated with correction and fusion surgery of four or more levels and could be followed for 2 years or longer. Bone density was measured before surgery using lumbar dual-energy X-ray absorptiometry (DXA) and spinal CT in all patients. The patients were divided into group A (n = 14) in which revision surgery was required for PJK or additional vertebral fracture and group B (n = 40) in which revision surgery was not required. We retrospectively investigated incidences of PJK, additional vertebral fracture, and PS loosening, perioperative parameters, radiographic parameters before and after surgery, and osteoporosis treatment administration rate.ResultsNo significant difference was noted in young adult mean (YAM) on DXA between groups A and B, respectively (P = 0.62), but the mean bone densities represented in HU of the T8 (P = 0.002) and T9 (P = 0.01) vertebral bodies on spinal CT were significantly lower in group A, whereas those of the L4 (P = 0.002) and L5 (P = 0.01) vertebral bodies were significantly higher in group A. The incidence of PJK was not significantly different (P = 0.07), but the incidence of additional vertebral fracture was significantly higher in group A (P < 0.001). The incidences of uppermost PS loosening within 3 months after surgery were 71% and 40% in groups A and B, respectively (P = 0.04).ConclusionsIn elderly patients who required revision surgery, the mean bone densities of vertebral bodies at T8 and T9 were significantly lower. The mean bone density represented in HU on spinal CT may be useful for risk assessment of and countermeasures against revision surgery after ASD surgery in elderly patients.

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“…Low BMD or osteoporosis has been con rmed as an important risk factor of PJF 6 . In order to reduce the incidence of fracture of UIV/UIV + 1, screw loosening and screw pull-out in osteoporotic spine, cement augmentation at UIV and UIV + 1 have already been used [7][8][9][10][11][12] . However, there still exists controversy about whether cement augmentation can reduce the incidence of the PJK/PJF 5,10,13 .…”

Section: Introductionmentioning

confidence: 99%

The Role of Prophylactic Vertebroplasty at UIV+1 and Cement-augmented Fenestrated Pedicle Screw for Prevention of PJK/PJF  in Patients With Osteoporosis: A Propensity Score–matched Analysis

Wang

et al. 2020

Preprint

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Objective: To elucidate the role of prophylactic vertebroplasty (PV) at UIV+1 and cement-augmented fenestrated pedicle screw (CAFPS) in prevention of PJK and PJF.Background: Cement augmentation at UIV and UIV+1 was found to prevent PJK and PJF. But most studies are retrospective and have a selection bias due to multifactorial etiology of PJF, making it difficult to identify the efficacy of prophylactic cement augmentation. Methods: We enrolled 208 surgically treated adult spinal deformity (ASD) patients who were followed for at least 2 years, to elucidate whether prophylactic cement augmentation was truly minimizing the risk of PJK and PJF in a uniform population from one center database. Patients were classified into two groups. Two comparable groups were propensity-matched with one to one nearest neighbor matching. The main outcome variables including PJK, PJF, pedicle screw loosening and cement leakage were compared.Results：After propensity score matching, there were 58 propensity-matched patients in group A and B (n=29 in each group) whose parameters including age, BMI, BMD, number of instrumented vertebrae, SVA, spinal-pelvic parameters and the frequency of UIV and LIV were similar. The incidence of PJK showed no significantly statistical difference between group A and B (10.3% vs 13.8%, p >0.99). Compared to group A, group B had a higher proportion of patients developing PJF (24.1% vs 0%, p=0.01). Pedicle screw loosening at UIV and (or) LIV showed no difference (24.1% vs 3.4%, p=0.052) between two groups. In group A, cement leakage was detected in 5 cases via fluoroscopy, but none of them had neurological deficit or pulmonary cement embolism.Conclusion: Combined application of CAFPS and PV could reduce the incidence of PJF, but it could not prevent the development of PJK in the surgical management of ASD with low BMD or osteoporosis.

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Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long-segment fusion for adult spinal deformity

Cited by 70 publications

References 46 publications

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study

The Role of Prophylactic Vertebroplasty at UIV+1 and Cement-augmented Fenestrated Pedicle Screw for Prevention of PJK/PJF  in Patients With Osteoporosis: A Propensity Score–matched Analysis

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Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long-segment fusion for adult spinal deformity

Cited by 70 publications

References 46 publications

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study

The Role of Prophylactic Vertebroplasty at UIV+1 and Cement-augmented Fenestrated Pedicle Screw for Prevention of PJK/PJF&nbsp; in Patients With Osteoporosis: A Propensity Score–matched Analysis

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The Role of Prophylactic Vertebroplasty at UIV+1 and Cement-augmented Fenestrated Pedicle Screw for Prevention of PJK/PJF in Patients With Osteoporosis: A Propensity Score–matched Analysis