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Agaronnik ND, Giberson-Chen C, Bono CM. Using advanced imaging to measure bone density, compression fracture risk, and risk for construct failure after spine surgery. Spine J 2024; 24:1135-1152. [PMID: 38437918 DOI: 10.1016/j.spinee.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/22/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting postoperative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and postoperative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure.
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Affiliation(s)
| | - Carew Giberson-Chen
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114
| | - Christopher M Bono
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114; Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114.
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Yamauchi I, Nakashima H, Ito S, Segi N, Ouchida J, Oishi R, Miyairi Y, Morita Y, Ode Y, Nagatani Y, Okada Y, Morishita K, Takeichi Y, Kagami Y, Tachi H, Ohshima K, Ogura K, Shinjo R, Ohara T, Tsuji T, Kanemura T, Imagama S. Preoperative low Hounsfield units in the lumbar spine are associated with postoperative mechanical complications in adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2824-2831. [PMID: 38695951 DOI: 10.1007/s00586-024-08261-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 03/23/2024] [Accepted: 04/03/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE To determine the most valid bone health parameter to predict mechanical complications (MCs) following surgery for adult spinal deformity (ASD). METHODS This multicenter study retrospectively examined the records of patients who had undergone fusion of three or more motion segments, including the pelvis, with a minimum two-year follow-up period. Patients with moderate and severe global alignment and proportion scores were included in the study and divided into two groups: those who developed MCs and those who did not. Bone mineral density (BMD) of the lumbar spine and femoral neck was measured using dual-energy X-ray absorptiometry, and Hounsfield units (HUs) were measured in the lumbar spine on computed tomography. Radiographic parameters were evaluated preoperatively, immediately after surgery, and at final follow-up. RESULTS Of 108 patients, 30 (27.8%) developed MCs, including 26 cases of proximal junctional kyphosis/failure, 2 of distal junctional failure, 6 of rod fracture, and 11 reoperations. HUs were significantly lower in patients who experienced MCs (113.7 ± 41.1) than in those who did not (137.0 ± 46.8; P = 0.02). BMD did not differ significantly between the two groups. The preoperative and two-year postoperative global tilt, as well as the immediately postoperative sagittal vertical axis, were significantly greater in patients who developed MCs than in those who did not (P = 0.02, P < 0.01, and P = 0.01, respectively). CONCLUSION Patients who experienced MCs following surgery for ASD had lower HUs than those who did not. HUs may therefore be more useful than BMD for predicting MCs following surgery for ASD.
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Affiliation(s)
- Ippei Yamauchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
- Department of Orthopedics and Spine Surgery, Meijo Hospital, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Jun Ouchida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Ryotaro Oishi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yuichi Miyairi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshinori Morita
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yukihito Ode
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yasuhiro Nagatani
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yuya Okada
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Kazuaki Morishita
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Yosuke Takeichi
- Department of Orthopedic Surgery, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Yujiro Kagami
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Hiroto Tachi
- Department of Orthopedic Surgery, Toyota Kosei Hospital, Toyota, Japan
| | - Kazuma Ohshima
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Keisuke Ogura
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Ryuichi Shinjo
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Tetsuya Ohara
- Department of Orthopedics and Spine Surgery, Meijo Hospital, Nagoya, Japan
| | - Taichi Tsuji
- Department of Orthopedic Surgery, Toyota Kosei Hospital, Toyota, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
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Tsuchiya K, Okano I, Dodo Y, Hayakawa C, Yamamura R, Maruyama H, Yasukawa T, Shirahata T, Kudo Y. Postoperative decrease in Hounsfield unit values at adjacent vertebrae after thoraco-pelvic fusion as a risk factor of proximal junctional kyphosis. J Orthop Res 2024. [PMID: 38924116 DOI: 10.1002/jor.25924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/16/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
Proximal junctional kyphosis and failure is a common complication of adult spinal deformity surgery, with osteoporosis as a risk factor. This retrospective study investigated the influence of long thoracolumbar fusion with pelvic fixation on regional bone density of adjacent vertebrae (Hounsfield units on computed tomography) and evaluated the association between bone loss and the incidence of proximal junctional kyphosis and failure. Patients who underwent long thoracolumbar fusion (pelvis to T10 or above) or single-level posterior lumbar interbody fusion (control group) between 2016 and 2022 were recruited. Routine computed tomography preoperatively and within 1-2 weeks postoperatively was performed. Postoperative changes in Hounsfield unit values in the vertebrae at one and two levels above the uppermost instrumented vertebrae (UIV + 1 and UIV + 2) were evaluated. Overall, 127 patients were recruited: 45 long fusion (age, 73.9 ± 5.6 years) and 82 proximal junctional kyphosis and failure (age, 72.5 ± 9.3 years). Postoperative computed tomography was performed at a median [interquartile range] of 3.0 [1.0-7.0] and 4.0 [1.0-7.0] days, respectively. In both groups, Hounsfield unit values at UIV + 2 were significantly decreased postoperatively. In the long-fusion group, Hounsfield unit values at UIV + 1 and UIV + 2 were significantly lower in patients with proximal junctional kyphosis and failure (within 18 months postoperatively) than in those without proximal junctional kyphosis and failure. Proximal junctional kyphosis and failure and long thoraco-pelvic fusion negatively affect regional Hounsfield unit values at adjacent levels immediately after surgery. Patients with subsequent proximal junctional kyphosis and failure show greater postoperative bone loss at adjacent levels than those without.
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Affiliation(s)
- Koki Tsuchiya
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Chikara Hayakawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Ryo Yamamura
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Hiroshi Maruyama
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
| | - Taiki Yasukawa
- Department of Orthopaedic Surgery, Showa University Koto Toyosu Hospital, Koto, Japan
| | - Toshiyuki Shirahata
- Department of Orthopaedic Surgery, Showa University Koto Toyosu Hospital, Koto, Japan
| | - Yoshifumi Kudo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Shinagawa, Japan
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Filley A, Baldwin A, Ben-Natan AR, Hansen K, Arora A, Xiao A, Hammond D, Chen C, Tweedt I, Rohde J, Link T, Berven S, Sawyer A. The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100327. [PMID: 38962714 PMCID: PMC11219986 DOI: 10.1016/j.xnsj.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 07/05/2024]
Abstract
Background Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes. Methods PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation. Results A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed. Conclusions Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.
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Affiliation(s)
- Anna Filley
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Avionna Baldwin
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Keith Hansen
- Department of General Surgery, University of California, San Francisco, CA, USA
| | - Ayush Arora
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Angel Xiao
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Deana Hammond
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Caressa Chen
- Loyola University Medical Center; Maywood IL, USA
| | - Isobel Tweedt
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, USA
| | - James Rohde
- Department of Integrative Biology, University of California Berkeley, USA
| | - Thomas Link
- Department of Radiology and Biomedical Imagery, University of California, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Aenor Sawyer
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
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Murata K, Otsuki B, Shimizu T, Sono T, Fujibayashi S, Matsuda S. Sagittal Section Hounsfield Units of the Upper Instrumented Vertebrae as a Predictor of Proximal Junctional Vertebral Fractures Following Adult Spinal Deformity Surgery. Asian Spine J 2024; 18:209-217. [PMID: 38650092 PMCID: PMC11065512 DOI: 10.31616/asj.2023.0339] [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: 10/16/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 04/25/2024] Open
Abstract
STUDY DESIGN A retrospective observational study. PURPOSE This study aimed to determine an accurate and convenient screening method for predicting proximal junctional fractures (PJFr) following surgery for adult spinal deformity (ASD) using computed tomography (CT)-based measurement of Hounsfield units (HUs). OVERVIEW OF LITERATURE CT-based measurement of HUs is an alternative tool for assessing bone mineral density. However, the optimal method for predicting adjacent vertebral fractures following spinal fusion using HUs remains unclear. METHODS This retrospective observational study included 42 patients who underwent reconstructive surgery for ASD. Elliptical regions of interest (ROIs) on the axial section and rectangular ROIs on the sagittal section were placed at the upper instrumented vertebrae (UIV), UIV+1, and UIV+2. In addition, the HU value of the L2 vertebra was used as the representative. RESULTS PJFr occurred in 28.6% of patients within 2 years following surgery. The HU values obtained from the axial sections of L2, UIV, UIV+1, and UIV+2 were not significantly associated with the incidence of PJFr within 2 years, except for the ROI set in the lower region of the L2 vertebra. However, the HU value of the anterior third of the UIV in the sagittal section was significantly lower in the PJFr group than in the nonPJFr group (87.0 vs. 160.3, p =0.001). A UIV HU value of <100 was associated with a higher incidence of PJFr than an HU vaue of >100 (p <0.05). CONCLUSIONS Measurements of HU in the anterior one-third of the UIV in the sagittal section demonstrated predictive ability for PJFr following ASD surgery. A UIV HU value of <100 emerged as a risk factor for PJFr.
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Affiliation(s)
- Koichi Murata
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Takashi Sono
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
- Department of Orthopaedic Surgery, Kijunkai Yoshikawa Hospital, Kyoto,
Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto,
Japan
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Hiyama A, Sakai D, Katoh H, Sato M, Watanabe M. Hounsfield Unit Values as an Adjunct Diagnostic Tool: Investigating Its Relationship with Bone Mineral Density and Vertebral Bone Quality in Lumbar Degenerative Disease Patients. World Neurosurg 2024; 183:e722-e729. [PMID: 38199461 DOI: 10.1016/j.wneu.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
OBJECTIVE With an increasing prevalence of osteoporosis due to demographic shifts, accurate diagnostic methods are vital, particularly before spinal surgeries. This research investigated the correlation between bone mineral density T-scores of the lumbar spine and femoral neck, Hounsfield Unit (HU) values from computed tomography (CT), and vertebral bone quality (VBQ) scores from Magnetic Resonance Imaging (MRI) in patients with lumbar degenerative disease. METHODS We analyzed data from 100 patients with lumbar degenerative disease who underwent CT, dual-energy X-ray absorptiometry (DXA), and MRI between 2019 and 2023. HU values were measured individually from L1 to L4, while T-scores were obtained from DXA scans of the lumbar spine and the femoral neck. The VBQ scores were derived from T1-weighted MRIs. RESULTS A notable association between the lumbar and femoral neck T-scores and HU values was found. The VBQ score had a faint correlation with HU values and lacked any with the T-score. Notably, the HU values derived via the Youden index and regression closely matched. Lumbar spine HU values related to T-scores of 85.6 and 84.4 and femoral neck T-scores of 98.9 and 103.6, with a low T-score at 98.9 and 104.6. CONCLUSIONS This study underscores a strong correlation between bone mineral density and HU values from CT scans in lumbar degenerative disease patients, suggesting the utility of HU measurements as an adjunct diagnostic tool for osteoporosis. However, the correlation with the VBQ score remains weak. Further multicenter studies are essential for more robust validation.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Ahn J, Ha KY, Kim YC, Kim KT, Kim SM, Ko T, Kim SI, Kim YH. Anterior Column Realignment Through Open Pre-posterior Release-Anterior-Posterior Fusion Versus Hybrid Minimally Invasive-Anterior-Posterior Fusion for Dynamic Sagittal Imbalance of the Spine. Global Spine J 2024:21925682241226658. [PMID: 38205787 DOI: 10.1177/21925682241226658] [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] [Indexed: 01/12/2024] Open
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVES To investigate the clinical and radiological outcomes after anterior column realignment (ACR) through pre-posterior release-anterior-posterior surgery (PAP) and minimally invasive surgery -lateral lumbar interbody fusion (MIS-LLIF) using hybrid anterior-posterior surgery (AP). METHODS A total of 91 patients who underwent ACR with long fusions from T10 vertebra to the sacropelvis with a follow-up period of at least 2 years after corrective surgery for adult spinal deformity were included and divided into two groups by surgical method: AP and PAP. AP was performed in 26 and PAP in 65 patients. Clinical outcomes and radiological parameters were investigated and compared. A further comparison was conducted after propensity score matching between the groups. RESULTS The more increase of LL and decrease of PI-LL mismatch were observed in the PAP group than in the AP group postoperatively. After propensity score matching, total operation time and intraoperative bleeding were greater, and intensive care unit care and rod fracture were more frequent in the PAP group than in the AP group with statistical significance. Reoperation rate was higher in PAP (29.2%) than in AP (16.7%) without statistical significance. CONCLUSIONS PAP provides a more powerful correction for severe sagittal malalignment than AP procedures. AP results in less intraoperative bleeding, operation time, and postoperative complications. Therefore, this study does not suggest that one treatment is superior to the other. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joonghyun Ahn
- Department of Orthopedic Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong-Chan Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ki-Tack Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sung-Min Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Taeyoung Ko
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Tsutsui S, Hashizume H, Iwasaki H, Takami M, Ishimoto Y, Nagata K, Yamada H. Sarcopenia at the upper instrumented vertebra is more significantly associated with proximal junctional kyphosis after long fusion for adult spinal deformity surgery than osteopenia. J Clin Neurosci 2023; 116:13-19. [PMID: 37597329 DOI: 10.1016/j.jocn.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/21/2023]
Abstract
Proximal junctional kyphosis (PJK) is a major mechanical complication after adult spinal deformity (ASD) surgery, and is multifactorial. Osteopenia and sarcopenia are patient risk factors, but it has not yet been well-documented which of them is the more significant risk factor. We retrospectively studied patients older than 50 years who underwent ASD surgery from the lower thoracic spine to the pelvis. In addition to patient demographic data and pre- and post-operative radiographic sagittal parameters (PI: pelvic incidence; LL: lumbar lordosis; SVA: sagittal vertical axis; PT: pelvic tilt), Hounsfield unit (HU) values on preoperative computed tomography and cross sectional area (CSA) and fatty infiltration ratio (FI%) of the paraspinal musculature (PSM) on preoperative magnetic resonance image were measured from the upper-instrumented vertebra (UIV) to UIV + 2 and averaged. PJK was observed in 11 of 29 patients. There was no statistical difference between the patients with and without PJK in age at surgery, sex, body mass index, bone mineral density, preoperative PI-LL, SVA, PT, postoperative PI-LL, SVA, PT, HU, and CSA. FI% in patients with PJK (25.0) was significantly higher than that (15.3) in patients without PJK (P = 0.001). Logistic regression analysis identified FI% of PSM as a significant independent factor of PJK (odds ratio, 1.973; 95% confidence interval, 1.290-5.554; P < 0.0001). After successful elimination of possible factors related to PJK other than sarcopenia and osteopenia, sarcopenia assessed by fatty degeneration of the PSM at the UIV was shown to be a more important factor than osteopenia for PJK after long fusion for ASD.
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Affiliation(s)
- Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan.
| | - Hiroshi Hashizume
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Masanari Takami
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Yuyu Ishimoto
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Keiji Nagata
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Hiroshi Yamada
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
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Blais M, Shahidi B, Anderson B, O'Brien E, Moltzen C, Iannacone T, Eastlack RK, Mundis GM. The influence of ligament biomechanics on proximal junctional kyphosis and failure in patients with adult spinal deformity. JOR Spine 2023; 6:e1277. [PMID: 37780835 PMCID: PMC10540824 DOI: 10.1002/jsp2.1277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/04/2023] [Accepted: 08/03/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose It is unknown whether the biomechanics of the posterior ligamentous complex (PLC) are impaired in individuals undergoing surgery for adult spinal deformity (ASD). Characterizing these properties may improve our understanding of proximal junctional kyphosis (PJK; defined as proximal junctional angle [PJA] of >10 deg from UIV-1 to UIV + 2), as well as proximal junctional failure (PJF; symptomatic PJK requiring revision). The purpose of this prospective observational study is to compare biomechanical properties of the PLC in individuals with ASD who do, and do not develop PJK or PJF within 1 year of spinal fusion surgery. Methods Intraoperative biopsies of PLC were obtained from 32 consecutive patients undergoing spinal fusions for ASD (>4 levels). Ligament peak force, tensile stress, tensile strain, and elastic modulus (EM) were measured with a materials testing system. Biomechanical properties and tissue dimensions were correlated with age, gender, BMI, vitamin D level, osteoporosis, sagittal alignment, PJA and change in PJA preoperatively, within 3 months, and at 1 year postoperatively. Results Longer ligaments were associated with greater PJA change at 3 months (p = 0.04), and thinner ligaments were associated with greater PJA change at 1 year (r = 0.57, p = 0.01). Greater EM was associated with greater PJA at both 3 months and 1 year (p = 0.03). Five participants had a change in PJA of >10 1 year postoperatively, and three participants demonstrated PJF. EM was significantly higher in individuals who required revision surgery (p = 0.003), and ligament length was greater (p = 0.03). Preoperative sagittal alignment was not related to incidence of revision surgery (p > 0.10). Conclusions The biomechanical properties of the PLC may be associated with higher risk for proximal failure. Ligaments that are longer, thinner, and less elastic are associated with higher postoperative PJA. Furthermore stiffer EM of the ligament is associated with the need for revision surgery.
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Affiliation(s)
- Micah Blais
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Bahar Shahidi
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Brad Anderson
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Eli O'Brien
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Courtney Moltzen
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Tina Iannacone
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Robert K. Eastlack
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Gregory M. Mundis
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
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Yoshie N, Maruo K, Arizumi F, Kishima K, Kusukawa T, Tachibana T. The Relationship between the Hounsfield Units Value of the Upper Instrumented Vertebra and the Severity of Proximal Junctional Fracture after Adult Spinal Deformity Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1086. [PMID: 37374290 DOI: 10.3390/medicina59061086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/03/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: In this retrospective cohort study, we investigate associations between the Hounsfield units (HU) value of upper instrumented vertebra (UIV) and proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery. Materials and Methods: The cohort consisted of 60 patients (mean age 71.7 years) who underwent long instrumented fusion surgery (≥6 vertebrae) for ASD with at least 1 year of follow-up. The preoperative bone mineral density (BMD) measured on DXA scans, the HU values at UIV and UIV+1, and the radiographic parameters were compared between the PJK and non-PJK groups. The severity of UIV fracture was assessed using a semiquantitative (SQ) grade. Results: PJK occurred in 43% of patients. No significant differences in patient age, sex, BMD, and preoperative radiographic parameters were observed between the PJK and non-PJK groups. The HU values of the UIV (103.4 vs. 149.0, p < 0.001) and UIV+1 (102.0 vs. 145.7, p < 0.001) were significantly lower in the PJK group. The cutoff values of HU at UIV and UIV+1 were 122.8 and 114.9, respectively. Lower HU values at UIV (Grade 1: 134.2, Grade 2: 109.6, Grade 3: 81.1, p < 0.001) and UIV+1 (Grade 1: 131.5, Grade 2: 107.1, Grade 3: 82.1, p < 0.001) were associated with severe SQ grade. Conclusions: Lower HU values at UIV and UIV+1 had a negative impact on signal incidence of PJK and were correlated with the severity of UIV fractures. Preoperative treatment of osteoporosis seems necessary for preoperative UIV HU values less than 120.
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Affiliation(s)
- Norichika Yoshie
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
| | - Keishi Maruo
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
| | - Fumihiro Arizumi
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
| | - Kazuya Kishima
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
| | - Tomoyuki Kusukawa
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
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11
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Hiyama A, Sakai D, Katoh H, Sato M, Watanabe M. Postoperative Radiological Improvement after Staged Surgery Using Lateral Lumbar Interbody Fusion for Preoperative Coronal Malalignment in Patients with Adult Spinal Deformity. J Clin Med 2023; 12:jcm12062389. [PMID: 36983389 PMCID: PMC10052673 DOI: 10.3390/jcm12062389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
This retrospective observational study evaluated improvement in coronal malalignment (CM) after anteroposterior staged surgery using lateral lumbar interbody fusion (LLIF) in patients with coronal lumbar curve adult spinal deformity (ASD). Sixty patients with ASD underwent surgery; 34 had SRS-Schwab type L lumbar curve. Patients with a coronal balance distance (CBD) ≥20 mm were diagnosed with CM. Using the Obeid CM classification, we classified the preoperative coronal pattern as concave CM (type 1) or convex CM (type 2). Demographic, surgical, and radiological parameters were compared. Whole-spine standing radiographs were assessed preoperatively and postoperatively. Twenty-three patients had type 1A, six had type 2A, five had no CM, and none had type 1B or 2B according to the Obeid CM classification. Compared with patients with Obeid type 1A, those with Obeid type 2A had significantly higher preoperative and postoperative coronal L4 tilts and a smaller change in corrected CBD (Δ|CBD|) (76.6 mm vs. 24.1 mm, p < 0.001). At the final follow-up, 58.6% (17/29 patients) of patients with SRS-Schwab type L CM showed improvement after corrective fusion using LLIF. Although the difference was not statistically significant, CM improved in 69.6% (16/23 patients) of patients with Obeid type 1A type but only 16.7% (1/6 patients) of those with Obeid type 2A type (p = 0.056). CM was more likely to remain after anteroposterior staged surgery using LLIF in patients with preoperative Obeid type 2A ASD.
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Affiliation(s)
- Akihiko Hiyama
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Daisuke Sakai
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Hiroyuki Katoh
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Masato Sato
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Masahiko Watanabe
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
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12
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Hiyama A, Katoh H, Nomura S, Sakai D, Sato M, Watanabe M. An Analysis of Whether a New Formula Can Predict Proximal Junctional Failure in Adult Spinal Deformity Patients with Global Kyphosis. World Neurosurg 2023; 170:e271-e282. [PMID: 36334711 DOI: 10.1016/j.wneu.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A new formula containing terms for age and sagittal curvature reported by the International Spine Study Group is ideal lumbar lordosis (iLL) = pelvic incidence - 0.3 thoracic kyphosis - 0.5Age + 10. However, there are no reports of whether proximal junctional failure (PJF) can be predicted using this formula. We assessed the utility of this formula in PJF in patients with adult spinal deformity with global kyphosis using the Roussouly classification. METHODS Forty-four patients with adult spinal deformity global kyphosis (mean age 70.0 years) who underwent multiple levels of lateral lumbar interbody fusion combined with posterior instrumentation were included. Patients were divided into 2 groups: PJF and non-PJF. Demographic, surgical, and radiological parameters were compared. The iLL was calculated according to the new formula, and spinal parameters were compared preoperatively, immediately after, and at the final follow-up. RESULTS PJF occurred in 11 of 44 (25.0%) patients. Patients with PJF had a large preoperative and postoperative TK, but there was no statistically significant difference in iLL between PJF and non-PJF patients (33.4° vs. 30.2°, P = 0.357). In addition, there was no statistically significant difference in LL and iLL changes (ΔiLL) immediately after surgery (19.0° vs. 23.4°, P = 0.379). Furthermore, there was no correlation between ΔiLL immediately after surgery and at the final follow-up and the proximal junctional angle at the final follow-up. CONCLUSIONS The results of ΔiLL suggest that overcorrection needs to be addressed but that this new formula, including age adjustment, may not predict PJF.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Satoshi Nomura
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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13
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Pu X, Zhou Q, Xu L, Yu Y, Liu Z, Qian B, Wang B, Zhu Z, Qiu Y, Sun X. Junctional Kyphosis after Correction with Long Instrumentation for Late Posttraumatic Thoracolumbar Kyphosis: Characteristics and Risk Factors. Orthop Surg 2023; 15:713-723. [PMID: 36597762 PMCID: PMC9977594 DOI: 10.1111/os.13642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Junctional kyphosis is a common complication after corrective long spinal fusion for adult spinal deformity. Whereas there is still a paucity of data on junctional kyphosis, specifically among late posttraumatic thoracolumbar kyphosis (LPTK) patients. Thus, the aim of this study was to investigate the characteristics and risk factors of junctional kyphosis in LPTK patients receiving long segmental instrumented fusion. METHODS We retrospectively reviewed a cohort of LPTK patients who had received long segmental instrumented fusion (>4 segments) in our center between January 2012 and January 2019. Radiographic assessments included the sagittal alignment, pelvic parameters, bone quality on CT images, and measurements of the cross-sectional area (CSA, cross-sectional area of muscle-vertebral body ratio × 100) and fat saturation fraction (FSF, cross-sectional area of fat-muscle body ratio × 100) of paraspinal muscles. Patients in this study were divided into those with junctional kyphosis or failure (Group J) and those without (Group NJ) during follow-up. Group J included patients with junctional kyphosis (Group JK) and patients with junctional failure (Group JF). RESULTS A total of 65 patients (16 males and 49 females, average age 56.5 ± 23.4 years) were enrolled in this study. After (32.7 ± 8.5) months follow-up, 15 patients (23.1%) experienced junctional kyphosis, and four of them deteriorated into junctional failure. Eighty percent (12/15) of junctional kyphosis was identified within 6 months after surgery. In comparison with Group NJ, Group J were older (P = 0.026), longer fusion levels (P < 0.001), greater thoracic kyphosis (P = 0.01), greater global kyphosis (P = 0.023), lower bone quality (P < 0.001), less CSA (P = 0.005) and higher FSF (P <0.001) of paraspinal muscles. Preoperative global kyphosis more than 48.5° (P = 0.001, odds ratio 1.793) and FSF more than 48.4 (P = 0.010, odds ratio 2.916) were identified as independent risk factors of junctional kyphosis. Based on the statistical differences among Group NJ, Group JK and Group JF (P < 0.001), Group JF had lower bone quality than Group NJ (P < 0.001) and Group JK (P = 0.015). In terms of patient-reported outcomes, patients in Group JF had worse outcomes in ODI and VAS scores, and PCS and MCS of SF-36 than Group NJ and group JK CONCLUSION: The prevalence of junctional kyphosis was 23.1% in LPTK patients after long segmental instrumented fusion. Preoperative hyperkyphosis and advanced fatty degeneration of paraspinal muscles were independent risk factors of junctional kyphosis. Patients with lower bone quality were more likely to develop junctional failure.
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Affiliation(s)
- Xiaojiang Pu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic SurgeryDrum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Yang Yu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Bangping Qian
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
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