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Risk factors for proximal junctional kyphosis after pediatric spinal deformity surgery with halo gravity traction. Childs Nerv Syst 2022; 38:1913-1922. [PMID: 35851613 DOI: 10.1007/s00381-022-05596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine risk factors for proximal junctional kyphosis (PJK) in pediatric patients with scoliosis undergoing halo gravity traction (HGT) prior to posterior spinal fusion (PSF). METHODS Data from consecutive patients who underwent PSF after HGT with 2-year follow-up were retrospectively collected from a single center. Patients were divided into two groups: PJK vs. no PJK. RESULTS Twenty-five patients (age 13.6 ± 3.1 years) underwent HGT for a mean of 42 ± 37 days. Eight patients (32%) developed radiographic PJK and 1 (4%) developed proximal junctional failure. PJK patients had greater loss of cervical lordosis (-17.4 ± 23.2 vs. 2.7 ± 16.2°, p < 0.05), greater increase in lumbar lordosis (9.3 ± 19.5 vs. -2.8 ± 12.8°; p = 0.034) during traction, and smaller overall major coronal curve angle correction (-16.8 ± 30.6 vs. -36.6 ± 16.4°; p = 0.026). From postoperative to last follow-up, PJK patients had a greater increase in upper end vertebrae (UEV) slope (3.3 ± 7.8 vs. -4.0 ± 7.7°; p = 0.004). Selection of UIV based on which vertebra was most level either pre-traction or in-traction was not associated with PJK development (p > 0.05). CONCLUSION In-traction radiographic changes of decreased cervical lordosis, decreased major coronal curve, increased lumbar lordosis, and disruption of cervical sagittal balance at last follow-up may have implications for level selection and risk of PJK.
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Yang B, Xu L, Wang M, Wang B, Zhu Z, Qiu Y, Sun X. Unmatched rod contouring at the proximal end predisposes to occurrence of junctional kyphosis in early-onset scoliosis patients undergoing traditional growing rods treatment. BMC Musculoskelet Disord 2022; 23:624. [PMID: 35768808 PMCID: PMC9241211 DOI: 10.1186/s12891-022-05564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
STUDY DESIGN A retrospective case series. OBJECTIVE To investigate whether unmatched rod contouring at the proximal end predisposed to the occurrence of proximal junctional kyphosis (PJK) in early-onset scoliosis (EOS) patients after traditional growing rods (TGR) treatment. TGR treatment has become a mainstay of treatment for EOS patients. PJK is one of the most common alignment-related complications. METHODS A consecutive series of EOS patients who had undergone TGR treatment were retrospectively reviewed. They were divided into PJK and non-PJK groups according to the occurrence of PJK or not. Demographic data, surgical strategies, and radiographic parameters were recorded and compared between groups. Proximal junctional angle (PJA) was defined as the angle between the caudal endplate of the UIV and the cephalad endplate of the second supradjacent vertebra above the UIV, while proximal rod contouring angle (PRCA) was defined as the angle of proximal rod contouring, which was represented by the angle between the cephalad endplate of the UIV and the caudal endplate of the second vertebra caudal to the UIV. Unmatched proximal rod contouring was regarded if the postoperative PRCA-PJA difference was greater than 5°. RESULTS This study finally included 73 patients. The mean age at the index surgery was 6.5 ± 2.2 years (range, 2-10 years). Mean follow-up lasted 5.0 ± 1.7 years (range, 2-9 years). They received mean 4.6 ± 1.6 lengthening procedures. There were 13 patients who were observed with PJK (18%). In comparison with the non-PJK group, the PJK group showed a larger preoperative major curve (82 ± 21° vs 70 ± 17°, P = 0.041) and global kyphosis (57 ± 6° vs. 44 ± 15°, P = 0.044). In addition, the PJK group had significantly larger postoperative PJA (10 ± 3 vs. 5 ± 3, P<0.001) and greater postoperative PJA-PRCA (6 ± 3 vs. 3 ± 3, P = 0.031). The proportion of patients with unmatched proximal rod contouring in PJK group was significantly higher than that in the non-PJK group (69% vs. 25%). Multiple logistic regression showed that preoperative GK>50°, postoperative PJA>10 and postoperative unmatched proximal rod contouring were the risk factors in predicting PJK after TGR treatment. CONCLUSION Approximately 18% EOS patients experienced PJK after TGR treatment. Unmatched proximal rod contouring may be an independent risk factor of PJK occurrence, in addition to greater preoperative GK and larger postoperative PJA. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Bo Yang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Muyi Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.
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Yang B, Xu L, Zhou Q, Qian Z, Wang B, Zhu Z, Qiu Y, Sun X. Relook into the Risk Factors of Proximal Junctional Kyphosis in Early Onset Scoliosis Patients: Does the Location of Upper Instrumented Vertebra in Relation to the Sagittal Apex Matter? Orthop Surg 2022; 14:1695-1702. [PMID: 35766793 PMCID: PMC9363734 DOI: 10.1111/os.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Growing rods surgery is the mainstay of treatment for early-onset scoliosis (EOS) while proximal junctional kyphosis (PJK) is one of the most commonly reported postoperative complications. We sought to investigate the impact of the location of upper instrumented vertebra (UIV) in relation to the sagittal apex on proximal junctional kyphosis in EOS after traditional growing rods (GRs) treatment. METHODS A total of 102 EOS patients who received traditional growing rods treatment with a follow-up of at least 2 years between 2009 and 2020 were retrospectively reviewed. Radiographic measurements were performed before and after the index surgery and at the latest follow-up. We investigated the coronal Cobb angle and spinopelvic parameters of the whole spine. The location of the UIV, apex, lower instrumented vertebra (LIV), inflection vertebra (IV), the number and distance of UIV-apex, LIV-apex and IV-apex were also recorded. Risk factors for PJK were analyzed by logistic regression analysis. RESULTS PJK was observed in 21 patients (20.6%) during the follow-up period. The PJK group showed a younger age at the index surgery (5.9 vs. 7.1 years, P = 0.042), more lengthening procedure times (5.0 vs. 4.0, P = 0.032), larger preoperative coronal Cobb angle (82.0 vs. 75.6°, P = 0.038), higher correction rate (51.2% vs. 44.4%, P = 0.047) and larger postoperative proximal junctional angle (PJA) (13.9 vs. 5.5°, P < 0.001) than the non-PJK group. The ratio of the number and distance from UIV-apex to IV-apex also differed significantly between the two groups. The logistic regression revealed that age at the index surgery ≤ 7 years, the ratio of the number from UIV- apex to IV- apex ≤ 0.6 and the ratio of the distance from UIV- apex to IV- apex ≤ 0.6 were independent risk factors for postoperative PJK. CONCLUSION Besides younger age, a closer location of UIV relative to the sagittal apex is identified to be an independent risk factor of postoperative PJK. Selection of UIV at a relatively farther location away from the sagittal apex might help prevent occurrence of PJK.
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Affiliation(s)
- Bo Yang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhuang Qian
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis. Spine Deform 2022; 10:257-266. [PMID: 34704232 DOI: 10.1007/s43390-021-00429-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Proximal junctional kyphosis (PJK) is a commonly encountered clinical and radiographic phenomenon after pediatric and adolescent spinal deformity surgery that may lead to post-operative deformity, pain, and dissatisfaction. Understanding the risk factors of PJK can be useful for pre-operative informed consent as well as to identify any potential preventative strategies. METHODS We performed a systematic review and critical analysis following the PRISMA statement in July 2019 by searching the PubMed, Scopus, and Embase databases, including all prior published studies. We included articles with data on PJK in patients with operative pediatric and adolescent scoliosis and those that detailed risk factors and/or preventative strategies for PJK. Levels of evidence were determined based on consensus. Findings were summarized and grades of recommendation were assigned by consensus. This study was registered in the PROSPERO database; 202,457. RESULTS Six hundred and thirty five studies were identified. Thirty-seven studies met criteria for inclusion into the analysis. No studies including neuromuscular scoliosis met inclusion criteria. No findings had Grade A evidence. There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction. There was no difference in incidence noted between etiology of the curvature. Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs. CONCLUSION Greater sagittal plane correction has Grade B evidence as a risk factor for PJK in both EOS and AIS populations. In EOS patients, an increased number of distractions and posterior element disruption are Grade B risk factors. In AIS patients, longer fusion constructs, higher pre-operative thoracic kyphosis and lumbar lordosis, and posterior (as opposed to anterior) constructs also contributed to PJK with Grade B evidence. These findings can guide informed consent and surgical management, and provide the foundation for future studies.
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FALCÃO RODRIGOMAGALHÃES, RAMIRO KAIORODRIGOBARRETO, LIMA MAURICIOCOELHO, VEIGA IVANGUIDOLIN, RISSO NETO MARCELOITALO, LEHOCZKI MAURICIOANTONELLI, ROSSATO ALEXANDERJUNQUEIRA, CAVALI PAULOTADEUMAIA. PREVALENCE OF PJK AFTER ARTHRODESIS IN PATIENTS WITH NEUROMUSCULAR SCOLIOSIS IN THE SECOND POSTOPERATIVE YEAR. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201903224042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective The primary objective of this study was to analyze the prevalence of PJK in patients with neuromuscular scoliosis submitted to posterior spinal arthrodesis with instrumentation. Proximal junctional kyphosis (PJK) is a frequent phenomenon that, due to its importance, began to be studied by several authors, who laid the foundations for the radiographic definition and possible risk factors for its occurrence after long spinal arthrodesis with instrumentation. Despite the large number of PJK studies, most were related to the occurrence of adolescent idiopathic scoliosis, adult deformity and early-onset scoliosis, with few being targeted to patients with congenital and neuromuscular scoliosis. Methods In this study, data from electronic medical records of patients with neuromuscular scoliosis who underwent posterior arthrodesis with instrumentation between the years 2014 and 2016 were analyzed. Information on age, gender, pathology and radiographic measurements were extracted from this sample at the 2nd and 24th postoperative months. Results A total of 39 patients with neuromuscular scoliosis were analyzed. The sample was predominantly male (58.87%) and the mean age was 14.05 years. PJK occurred in 18 patients during the two years following surgery, with a prevalence of 46.15%. The incidence of PJK in the 2nd and 24th postoperative months was 23.1% and 30%, respectively. Conclusions A prevalence of PJK of 46.15% was found in patients with neuromuscular scoliosis treated surgically with posterior instrumentation after two years of follow-up, as compared to previous results . Level of Evidence III; Cross-sectional observational study.
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Affiliation(s)
- RODRIGO MAGALHÃES FALCÃO
- Universidade Estadual de Campinas, Brazil; Associação de Assistência à Criança Deficiente, Brazil
| | | | - MAURICIO COELHO LIMA
- Universidade Estadual de Campinas, Brazil; Associação de Assistência à Criança Deficiente, Brazil
| | - IVAN GUIDOLIN VEIGA
- Universidade Estadual de Campinas, Brazil; Associação de Assistência à Criança Deficiente, Brazil
| | | | | | | | - PAULO TADEU MAIA CAVALI
- Universidade Estadual de Campinas, Brazil; Associação de Assistência à Criança Deficiente, Brazil
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The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset: Mean 4.5-Year Follow-up. J Pediatr Orthop 2020; 40:261-266. [PMID: 32501899 DOI: 10.1097/bpo.0000000000001516] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS). METHODS A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed. RESULTS At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038). CONCLUSIONS In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs. LEVEL OF EVIDENCE Level III.
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7
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Joukhadar N, Kubat O, Heflin J, Yasin MS, McClung A, Flynn T, Sheppard M, Skaggs D, El-Hawary R. Superior Extension of Upper Instrumented Vertebrae in Distraction-based Surgery: A Surrogate for Clinically Significant Proximal Junctional Kyphosis. Spine Deform 2019; 7:371-375. [PMID: 30660235 DOI: 10.1016/j.jspd.2018.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 07/15/2018] [Accepted: 08/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) is a reported complication of distraction-based growth-friendly surgery for early-onset scoliosis (EOS). A potential consequence of PJK is revision surgery with superior extension of the upper instrument vertebrae (UIV). The purpose of this study was to determine the risk of radiographic and clinically significant PJK during growth-friendly surgery. METHODS This is a retrospective review of children treated with distraction-based growth-friendly surgeries from two EOS registries with minimum two-year follow-up. PJK is defined as clinically significant in this study if surgery with superior extension of the UIV was performed. RESULTS Of 419 total patients, there was a 20% risk of developing clinically significant PJK (24% rib vs. 15% spine-based anchors, p = .03). These patients had a mean preoperative age of 5.6 years (5.2-year rib vs. 6.0-year spine, p < .001), scoliosis of 73° (69° rib vs. 77° spine, p < .001), and kyphosis of 51° (47° rib vs. 56° spine, p < .01). Regression analysis demonstrated that these differences in age, scoliosis, and kyphosis between anchor type did not account for a significant proportion of the measured variance. CONCLUSIONS There was a 20% risk of developing clinically significant PJK, with a slightly higher risk for patients treated with rib-based proximal anchors (24%) than for those patients treated with spine-based proximal anchors (15%). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nadim Joukhadar
- Dalhousie University, 6299 South St, Halifax NS B3H 4R2, Canada
| | - Ozren Kubat
- University of Zagreb, School of Medicine, Šalata ul. 2, 10000, Zagreb, Croatia
| | - John Heflin
- Primary Children's Hospital, 100 Mario Capecchi Dr, Salt Lake City, UT 84113, USA
| | - Mohamad S Yasin
- Izaak Walton Killam (IWK) Health Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada
| | | | | | - Megan Sheppard
- Universite de Sherbrooke, 2500, boul. de l'Université, Sherbrooke, Québec J1K 2R1, Canada
| | - David Skaggs
- Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Ron El-Hawary
- Izaak Walton Killam (IWK) Health Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada.
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Hardesty CK, Huang RP, El-Hawary R, Samdani A, Hermida PB, Bas T, Balioğlu MB, Gurd D, Pawelek J, McCarthy R, Zhu F, Luhmann S. Early-Onset Scoliosis: Updated Treatment Techniques and Results. Spine Deform 2019; 6:467-472. [PMID: 29886921 DOI: 10.1016/j.jspd.2017.12.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/22/2017] [Accepted: 12/25/2017] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN This is a review of the current literature on early-onset scoliosis (EOS) techniques and treatment written by the Growing Spine Committee of the Scoliosis Research Society. OBJECTIVES The Growing Spine Committee of the Scoliosis Research Society sought to update the information available on the definition and treatment of EOS, including new information about existing techniques. SUMMARY OF BACKGROUND DATA EOS represents a diverse, heterogeneous, and clinically challenging group of spinal disorders occurring in children under the age of 10. Our understanding of EOS has changed dramatically in the last 15 years, and management of EOS has changed even more rapidly in the last five years. METHODS The Growing Spine Committee of the Scoliosis Research Society has embarked upon a review of the most current literature on EOS techniques and treatment. RESULTS This white paper provides recent updates on current techniques, including a summary of new modalities, indications, contraindications, and clinical results. CONCLUSIONS Although treatment of EOS is still challenging and complicated, the evolution of options and knowledge presents hope for better understanding and management in the future. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Christina K Hardesty
- Rainbow Babies and Children's Hospital, Case Western Reserve University, 11100 Euclid Avenue, RBC 6081, Cleveland, OH 44106, USA.
| | - Robert P Huang
- Studer Family Children's Hospital Scoliosis and Pediatric Orthopaedic Surgery, 4541 N. Davis Highway, Suite A, Pensacola, FL 32503, USA
| | - Ron El-Hawary
- IWK Heath Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada
| | - Amer Samdani
- Shriners Hospitals for Children, 3551 N Broad St, Philadelphia, PA 19140, USA
| | - Paloma Bas Hermida
- Hospital Universitario y Politecnico La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Teresa Bas
- Hospital Universitario y Politecnico La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Mehmet Bülent Balioğlu
- Department of Orthopaedics, Istinye University Liv Hospital, Asik Veysel mah. Suleyman Demirel Cad. No:1 34510, Esenyurt, Istanbul, Turkey
| | - David Gurd
- San Diego Diego Spine Foundation, 6190 Cornerstone Ct East, Ste 212, San Diego, CA 92121, USA
| | - Jeff Pawelek
- Cleveland Clinic Children's Hospital, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Richard McCarthy
- Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72202, USA
| | - Feng Zhu
- Chinese University of Hong Kong, Sino Building, Chung Chi Rd, Sha Tin, Hong Kong, China
| | - Scott Luhmann
- Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, USA
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Safaee MM, Deviren V, Dalle Ore C, Scheer JK, Lau D, Osorio JA, Nicholls F, Ames CP. Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity. J Neurosurg Spine 2018; 28:512-519. [DOI: 10.3171/2017.9.spine1710] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEProximal junctional kyphosis (PJK) is a well-recognized, yet incompletely defined, complication of adult spinal deformity surgery. There is no standardized definition for PJK, but most studies describe PJK as an increase in the proximal junctional angle (PJA) of greater than 10°–20°. Ligament augmentation is a novel strategy for PJK reduction that provides strength to the upper instrumented vertebra (UIV) and adjacent segments while also reducing junctional stress at those levels.METHODSIn this study, ligament augmentation was used in a consecutive series of adult spinal deformity patients at a single institution. Patient demographics, including age; sex; indication for surgery; revision surgery; surgical approach; and use of 3-column osteotomies, vertebroplasty, or hook fixation at the UIV, were collected. The PJA was measured preoperatively and at last follow-up using 36-inch radiographs. Data on change in PJA and need for revision surgery were collected. Univariate and multivariate analyses were performed to identify factors associated with change in PJA and proximal junctional failure (PJF), defined as PJK requiring surgical correction.RESULTSA total of 200 consecutive patients were included: 100 patients before implementation of ligament augmentation and 100 patients after implementation of this technique. The mean age of the ligament augmentation cohort was 66 years, and 67% of patients were women. Over half of these cases (51%) were revision surgeries, with 38% involving a combined anterior or lateral and posterior approach. The mean change in PJA was 6° in the ligament augmentation group compared with 14° in the control group (p < 0.001). Eighty-four patients had a change in PJA of less than 10°. In a multivariate linear regression model, age (p = 0.016), use of hook fixation at the UIV (p = 0.045), and use of ligament augmentation (p < 0.001) were associated with a change in PJA. In a separate model, only ligament augmentation (OR 0.193, p = 0.012) showed a significant association with PJF.CONCLUSIONSLigament augmentation represents a novel technique for the prevention of PJK and PJF. Compared with a well-matched historical cohort, ligament augmentation is associated with a significant decrease in PJK and PJF. These data support the implementation of ligament augmentation in surgery for adult spinal deformity, particularly in patients with a high risk of developing PJK and PJF.
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Affiliation(s)
| | - Vedat Deviren
- 2Orthopedic Surgery, University of California, San Francisco, California
| | | | - Justin K. Scheer
- 3Department of Neurological Surgery, University of Illinois, Chicago, Illinois; and
| | - Darryl Lau
- Departments of 1Neurological Surgery and
| | | | - Fred Nicholls
- 4Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - Christopher P. Ames
- Departments of 1Neurological Surgery and
- 2Orthopedic Surgery, University of California, San Francisco, California
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10
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What is the Risk of Developing Proximal Junctional Kyphosis During Growth Friendly Treatments for Early-onset Scoliosis? J Pediatr Orthop 2017; 37:86-91. [PMID: 26192880 DOI: 10.1097/bpo.0000000000000599] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rib-based and spine-based systems are commonly used distraction-based growth friendly treatments for early-onset scoliosis (EOS). Our primary purpose was to determine the risk of developing postoperative proximal junctional kyphosis (PJK) during distraction-based growth friendly surgery. METHODS A multicenter, retrospective, radiographic comparison was performed for a group of 40 children with EOS who were treated with posterior distraction-based implants. PJK was defined as proximal junction sagittal angle (PJA)≥10 degrees and PJA at least 10 degrees greater than preoperative. RESULTS Eight subjects (20%) at immediate postoperative follow-up and 11 subjects (27.5%) at minimum 2-year follow-up had developed PJK. The risk of developing PJK between rib-based and spine-based growing systems was not significantly different at immediate postoperative (17% vs. 25%) or at final (25% vs. 31%) follow-ups.Further analysis combining both treatment groups demonstrated that PJK subjects were significantly older at time of initial surgery (7.1 y PJK vs. 5.0 y no PJK). Radiographic comparisons between PJK versus no PJK: Preoperative scoliosis (69.9 vs. 76.0 degrees), thoracic kyphosis (45.1 vs. 28.7 degrees), lumbar lordosis (53.1 vs. 44.0 degrees), PJA (2.2 vs. 2.8 degrees), sagittal vertical axis (1.5 vs. 2.6 cm), pelvic incidence (52.8 vs. 47.4 degrees), pelvic tilt (14.3 vs. 8.7 degrees), and sacral slope (37.7 vs. 35.9 degrees). At both initial postoperative and at final follow-up visits, a significant difference was found for cervical lordosis 32.2 versus 14.0 degrees and 42.0 versus 16.6 degrees, respectively. Risk ratio for developing PJK at final follow-up was 2.8 for subjects with preoperative thoracic hyperkyphosis and was 3.1 for subjects with high pelvic incidence (P<0.05). CONCLUSIONS The risk of developing PJK during distraction-based growth friendly treatment for EOS was 20% immediately after implantation and 28% at minimum 2-year follow-up, with no difference observed between rib-based and spine-based treatment groups. As this study identifies a significant risk of developing PJK during the treatment of EOS, it allows clinicians to preoperatively council patients and their families about this possible complication. In addition, several potential risk factors for the development of postoperative PJK were identified, but should be investigated further in future studies. LEVEL OF EVIDENCE Level III-therapeutic study (retrospective, comparative).
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Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976) 2014; 39:2093-102. [PMID: 25271516 DOI: 10.1097/brs.0000000000000627] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review of literature. OBJECTIVE To perform a comprehensive English language systematic literature review of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), concentrating on incidence, risk factors, health related quality of life impact, prevention strategy, and classification systems. SUMMARY OF BACKGROUND DATA PJK and PJF are well described clinical pathologies and are a frequent cause of revision surgery. The development of a PJK classification that correlates with clinical outcomes and guides treatment decisions and possible prevention strategies would be of significant benefit to patients and surgeons. METHODS The phrases "proximal junctional," "proximal junctional kyphosis," and "proximal junctional failure" were used as search terms in PubMed for all years up to 2014 to identify all articles that included at least one of these terms. RESULTS Fifty-three articles were identified overall. Eighteen articles assessed for risk factors. Eight studies specifically reviewed prevention strategies. There were no randomized prospective studies. There were 3 published studies that have attempted to classify PJK. The reported incidence of PJK ranged widely, from 5% to 46% in patients undergoing spinal instrumentation and fusion for adult spinal deformity. It is reported that 66% of PJK occurs within 3 months and 80% within 18 months after surgery. The reported revision rates due to PJK range from 13% to 55%. Modifiable and nonmodifiable risk factors for PJK have been characterized. CONCLUSION PJK and PJF affect many patients after long segment instrumentation after the correction of adult spinal deformity. The epidemiology and risk factors for the disease are well defined. A PJK and PJF scoring system may help describe the severity of disease and guide the need for revision surgery. The development and prospective validation of a PJK classification system is important considering the prevalence of the problem and its clinical and economic impact. LEVEL OF EVIDENCE N/A.
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Al Khudairy A, Gauthier L, Heflin JA, Fletcher ND, Matz J, Soroceanu A, El-Hawary R. Reliability of Proximal Junctional Kyphosis Measurements for Young Children With Scoliosis. Spine Deform 2014; 2:448-453. [PMID: 27927404 DOI: 10.1016/j.jspd.2014.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 05/03/2014] [Accepted: 07/08/2014] [Indexed: 11/15/2022]
Abstract
DESIGN Retrospective comparison. OBJECTIVES To determine whether the choice of proximal junctional kyphosis (PJK) definition affects reported rates and reliability of measurement of PJK for the same group of children treated with growth-friendly surgery. BACKGROUND Distraction-based surgery has been associated with the development of PJK, which may lead to premature implant failure and may affect the upper instrumented level. Proximal junctional kyphosis has not been clearly defined in the literature and recent studies have used various definitions, resulting in widely varying rates of PJK. As a first step toward defining risk factors that may lead to clinically significant PJK, an evaluation of definitions of PJK should be performed. METHODS The researchers analyzed radiographs of 36 children who were treated with growth-friendly surgery. The rates of PJK were determined using 3 recently described definitions. Five observers each measured the radiographs 2 weeks apart. Reliability was measured using the kappa statistic and intraclass correlation. RESULTS At 2-year follow-up, rates of PJK varied between 6% and 42% depending on the definition used. Interobserver agreement for PJK at time 1 yielded fair agreement for definition 1 (κ = 0.31), moderate for definition 2 (κ = 0.40), and fair for definition 3 (κ = 0.38). Interobserver agreement for junctional angle at time 1 was fair (intraclass correlation coefficient [ICC], 0.48) for definition 1, good (ICC, 0.71) for definition 2, and fair (ICC, 0.55) for definition 3. Intra-observer agreement between times 1 and 2 for junctional angle was good (ICC, 0.61) for definition 1, excellent (ICC, 0.82) for Definition 2, and good (ICC, 0.69) for definition 3. CONCLUSIONS When assessed with the same group of children, rates of PJK varied depending on the definition used. Interobserver reliability was fair to moderate; however, better interobserver and intra-observer agreement were noted with definition 2.
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Affiliation(s)
- Ammar Al Khudairy
- Department of Orthopaedics, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax NS B3K 6R8, Canada
| | - Luke Gauthier
- Department of Orthopaedics, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax NS B3K 6R8, Canada
| | - John A Heflin
- Department of Orthopaedics, University of Utah, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 4550, Salt Lake City, UT 84113, USA
| | - Nicholas D Fletcher
- Department of Orthopaedics, Emory Orthopaedics and Spine Center, 59 Executive Park South, Atlanta, GA 30329, USA
| | - Jacob Matz
- Department of Orthopaedics, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax NS B3K 6R8, Canada
| | - Alexandra Soroceanu
- Department of Orthopaedics, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax NS B3K 6R8, Canada
| | - Ron El-Hawary
- Department of Orthopaedics, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax NS B3K 6R8, Canada.
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