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Daher M, Kreichati G, Kharrat K, Maroun R, Aoun M, Chalhoub R, Diebo BG, Daniels AH, Sebaaly A. Dual Versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis. World Neurosurg 2024; 188:93-98. [PMID: 38754547 DOI: 10.1016/j.wneu.2024.05.051] [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: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries. METHODS PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss. RESULTS Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25-0.99, P = 0.05). Furthermore, operative room time (mean differences = -82.73; 95% CI: -111.42 to -54.03, P < 0.001) and LOS (mean differences = -0.91; 95% CI: -1.12 to -0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes. CONCLUSIONS The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.
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Affiliation(s)
- Mohammad Daher
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA; Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Gaby Kreichati
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | | | - Marven Aoun
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Ralph Chalhoub
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Bassel G Diebo
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Amer Sebaaly
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon.
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2
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Pinter ZW, Bernatz J, Mikula AL, Lakomkin N, Pennington ZA, Michalopoulos GD, Nassr A, Freedman BA, Bydon M, Fogelson J, Sebastian AS, Elder BD. Paraspinal Sarcopenia and Lower Hounsfield Units are Independent Predictors of Increased Risk for Proximal Junctional Complications Following Thoracolumbar Fusions Terminating in the Upper Thoracic Spine. Global Spine J 2024:21925682241270094. [PMID: 39091148 DOI: 10.1177/21925682241270094] [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: 08/04/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The impact of paraspinal sarcopenia following fusions that extend to the upper thoracic spine remain unknown. The purpose of the present study was to assess the impact of sarcopenia on the development of PJK and PJF following spine fusion surgery from the upper thoracic spine to the pelvis. METHODS We performed a retrospective review of patients who underwent spine fusion surgery that extended caudally to the pelvis and terminated cranially between T1-6. The cohort was divided into 2 groups: (1) patients without PJK or PJF and (2) patients with PJK and/or PJF. Univariate and multivariate analyses were performed to determine risk factors for the development of proximal junctional complications. RESULTS We identified 81 patients for inclusion in this study. Mean HU at the UIV was 186.1 ± 47.5 in the cohort of patients without PJK or PJF, which was substantially higher than values recorded in the PJK/PJF subgroup (142.4 ± 40.2) (P < 0.001). Severe multifidus sarcopenia was identified at a higher rate in the subgroup of patients who developed proximal junction pathology (66.7%) than in the subgroup of patients who developed neither PJK nor PJF (7.4%; P < 0.001). Multivariate analysis demonstrated both low HU at the UIV and moderate-severe multifidus sarcopenia to be risk factors for the development of PJK and PJF. CONCLUSIONS Severe paraspinal sarcopenia and diminished bone density at the UIV impart an increased risk of developing PJK and PJF in following thoracolumbar fusions from the upper thoracic spine to the pelvis.
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Affiliation(s)
| | - James Bernatz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anthony L Mikula
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jeremy Fogelson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Fawcett MA, Schwend RM. Surgical technique: proximal extension of instrumentation using sublaminar bands for salvage of postoperative proximal junctional failure in pediatric patients. Spine Deform 2024; 12:971-978. [PMID: 38536654 DOI: 10.1007/s43390-024-00851-w] [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: 04/26/2023] [Accepted: 02/20/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Proximal junctional failure is a complication that can occur following posterior spine surgery with instrumentation. The ability to surgically revise this complication is important for the spine surgeon, yet there is little literature on the topic, especially for pediatric patients. METHODS The technique we describe involves proximal extension of the existing instrumentation using paired levels of sublaminar bands that allows for a smooth transition of forces at the junction of instrumented and non-instrumented regions of the spine. RESULTS The results of this technique have been promising with a case series demonstrating improved radiographic and clinical outcomes for eight children at a minimum of 1 year follow-up. CONCLUSION This a reliable, effective, and safe technique for salvage of PJF in children that uses posterior osteotomies and proximal extension of the instrumentation using sublaminar bands, resulting in gradual load sharing correction to restore sagittal balance.
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Affiliation(s)
| | - Richard M Schwend
- Department of Orthopaedic Surgery and Musculoskeletal Sciences, Children's Mercy Hospital, Kansas City, MO, USA
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Deng W, Zhou Y, Zhou Q, Yin Y, Song Y, Feng G. Simplified S1 vertebral bone quality score independently predicts proximal junctional kyphosis after surgery for degenerative lumbar scoliosis. J Orthop Surg Res 2024; 19:238. [PMID: 38615068 PMCID: PMC11015578 DOI: 10.1186/s13018-024-04722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/05/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE Our study aimed to assess the effectiveness of the simplified S1 vertebral bone quality (VBQ) score in predicting the incidence of proximal junctional kyphosis (PJK) after surgery for degenerative lumbar scoliosis (DLS). METHODS We reviewed 122 patients with DLS who underwent posterior lumbar decompression and long-segment fusion surgery in our hospital from January 2016 to December 2020. The patients were classified into PJK group and non-PJK group. S1 VBQ scores are determined by signal intensity measurements taken from the mid-sagittal plane of T1-weighted non-contrast MRI. Logistic regression analysis was used to identify factors associated with PJK. Receiver-operating characteristic curve (ROC) analysis was used to evaluate the value of S1 VBQ score in predicting pedicle PJK after DLS. RESULTS 122 DLS patients (90 females and 32 males) met the inclusion criteria. In addition, 27 patients (22.13%) had PJK at the time of last follow-up. VBQ was higher in PJK patients than non-PJK patients (3.58 ± 0.67 vs. 3.08 ± 0.54, p < 0.001). Preoperatively, patients in the PJK group had a greater TLK than those in the non-PJK group (20.00 ± 6.22 vs. 16.86 ± 5.38, p = 0.011). After surgery, patients in the PJK group had greater TLK (p < 0.001) and PJA (p < 0.001) compared with the non-PJK group. At final FU, patients in the PJK group had greater TK (p = 0.002), TLK (p < 0.001), SVA (p < 0.001), and PJA (p < 0.001) than patients in the non-PJK group (Table 4). In multivariate logistic regression analysis, higher VBQ score (OR 4.565, 95% CI 1.43-14.568, p = 0.010), advanced age (OR 1.119, 95% CI 1.021-1.227, p = 0.016), and larger TLK (OR 1.191, 95% CI 1.041-1.362, p = 0.011) were significant predictors of postoperative PJK in patients with DLS (Table 6). A statistically significant positive correlation existed between VBQ score and PJA change (r = 0.370, p < 0.001). We created ROC curves for VBQ scores as predictors of PJK with a diagnostic accuracy of 72.1% (95% CI 60.15-82.9%.The ideal limit for the VBQ score was 3.205 (sensitivity: 77.8%, specificity: 81.4%). CONCLUSION To the best of our knowledge, this is the first study to evaluate the effectiveness of the S1 VBQ score in predicting postoperative PJK in DLS. Our study included major risk factors and found that S1 VBQ score was a significant predictor of PJK in patients undergoing DLS surgery. The higher the S1 VBQ score, the higher the probability of PJK.
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Affiliation(s)
- Wei Deng
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
- Department of Orthopedics, Pidu District People's Hospital/The Third Affiliated Hospital of Chengdu Medical College, Chengdu, 611730, China
| | - Yue Zhou
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qingsong Zhou
- Department of Orthopedics, Pidu District People's Hospital/The Third Affiliated Hospital of Chengdu Medical College, Chengdu, 611730, China
| | - Yong Yin
- Department of Orthopedics, Pidu District People's Hospital/The Third Affiliated Hospital of Chengdu Medical College, Chengdu, 611730, China
| | - Yueming Song
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ganjun Feng
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China.
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5
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Ani F, Ayres EW, Soroceanu A, Mundis GM, Smith JS, Gum JL, Daniels AH, Klineberg EO, Ames CP, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Protopsaltis TS. Functional Alignment Within the Fusion in Adult Spinal Deformity (ASD) Improves Outcomes and Minimizes Mechanical Failures. Spine (Phila Pa 1976) 2024; 49:405-411. [PMID: 37698284 DOI: 10.1097/brs.0000000000004828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/03/2023] [Indexed: 09/13/2023]
Abstract
STUDY DESIGN Retrospective review of an adult deformity database. OBJECTIVE To identify pelvic incidence (PI) and age-appropriate physical function alignment targets using a component angle of T1-pelvic angle within the fusion to define correction and their relationship to proximal junctional kyphosis (PJK) and clinical outcomes. SUMMARY OF BACKGROUND DATA In preoperative planning, a patient's PI is often utilized to determine the alignment target. In a trend toward more patient-specific planning, age-specific alignment has been shown to reduce the risk of mechanical failures. PI and age have not been analyzed with respect to defining a functional alignment. METHODS A database of patients with operative adult spinal deformity was analyzed. Patients fused to the pelvis and upper-instrumented vertebrae above T11 were included. Alignment within the fusion correlated with clinical outcomes and PI. Short form 36-Physical Component Score (SF36-PCS) normative data and PI were used to compute functional alignment for each patient. Overcorrected, under-corrected, and functionally corrected groups were determined using T10-pelvic angle (T10PA). RESULTS In all, 1052 patients met the inclusion criteria. T10PA correlated with SF36-PCS and PI (R=0.601). At six weeks, 40.7% were functionally corrected, 39.4% were overcorrected, and 20.9% were under-corrected. The PJK incidence rate was 13.6%. Overcorrected patients had the highest PJK rate (18.1%) compared with functionally (11.3%) and under-corrected (9.5%) patients ( P <0.05). Overcorrected patients had a trend toward more PJK revisions. All groups improved in HRQL; however, under-corrected patients had the worst 1-year SF36-PCS offset relative to normative patients of equivalent age (-8.1) versus functional (-6.1) and overcorrected (-4.5), P <0.05. CONCLUSIONS T10PA was used to determine functional alignment, an alignment based on PI and age-appropriate physical function. Correcting patients to functional alignment produced improvements in clinical outcomes, with the lowest rates of PJK. This patient-specific approach to spinal alignment provides adult spinal deformity correction targets that can be used intraoperatively.
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Affiliation(s)
- Fares Ani
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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Nguyen AQ, Rodriguez C, Kumar R, Gupta S, Anderson DE, Saifi C. Biomechanical analysis of complications following T10-Pelvis spinal fusion: A population based computational study. J Biomech 2024; 165:111969. [PMID: 38394952 DOI: 10.1016/j.jbiomech.2024.111969] [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: 04/13/2023] [Revised: 01/22/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are challenging complications of long fusion constructs for the treatment of adult spinal deformity. The objective of this study is to understand the biomechanical stresses proximal to the upper instrumentation of a T10-pelvis fusion in a large patient cohort. The pre-fusion models were subject-specific thoracolumbar spine models that incorporate the height, weight, spine curvature, and muscle morphology of 250 individuals from the Framingham Heart Study Multidetector CT Study. To create post-fusion models, the subject-specific models were further modified to eliminate motion between the intervertebral joints from T10 to the pelvis. OpenSim analysis tools were used to calculate the medial lateral shear force, anterior posterior shear force, and compressive force on the T9 vertebra during the static postures. Differences between pre-fusion and post-fusion T9 biomechanics were consistent between increased segmental mobility and unchanged segmental mobility conditions. For all static postures, compression decreased (p < 0. 0005). Anterior-posterior shear force significantly increased (p < 0. 0005) during axial twist and significantly increased (p < 0. 0005) during trunk flexion. Medial lateral shear force significantly increased (p < 0. 0005) during axial twist. This computational study provided the first use of subject-specific models to investigate the biomechanics of long spinal fusions. Patients undergoing T10-Pelvis fusion were predicted to have increased shear forces and decreased compressive force at the T9 vertebra, independent of change in segmental mobility. The computational model shows potential for the investigation of spinal fusion biomechanics to reduce the risk of PJK or PJF.
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Affiliation(s)
- Austin Q Nguyen
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, United States
| | - Christian Rodriguez
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, United States
| | - Rachit Kumar
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, United States
| | - Sachin Gupta
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Dennis E Anderson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Comron Saifi
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, United States.
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7
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Rezvani M, Veisi S, Sourani A, Ahmadian H, Foroughi M, Mahdavi SB, Nik Khah R. Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up. Injury 2024; 55:111164. [PMID: 37923678 DOI: 10.1016/j.injury.2023.111164] [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: 09/01/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE To investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion. METHOD This case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant. RESULT Ninety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05). CONCLUSION The introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.
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Affiliation(s)
- Majid Rezvani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaahin Veisi
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Arman Sourani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran; Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Ahmadian
- Department of Neurosurgery, Babol University of Medical Sciences, Mazandaran, Iran
| | - Mina Foroughi
- Isfahan Medical Students' Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sadegh Baradaran Mahdavi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Student Research Committee, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan, Iran
| | - Roham Nik Khah
- Isfahan Medical Students' Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
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O'Hehir MM, O'Connor TE, Mariotti BL, Soliman MAR, Quiceno E, Gupta MC, Berven S, Pollina J, Polly DW, Mullin JP. Tension Parameters of Junctional Tethers in Proximal Junction Kyphosis: A Cadaveric Biomechanical Study. World Neurosurg 2024; 182:e798-e806. [PMID: 38097169 DOI: 10.1016/j.wneu.2023.12.041] [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: 09/21/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE Proximal junctional failure following surgical correction for adult spinal deformity significantly impacts quality of life and increases the economic burden of treating underlying spinal deformity. The objective of this cadaver study was to determine optimal tension parameters in junctional tethers for proximal junctional kyphosis prevention. METHODS Cadaveric specimens were used to establish the optimal tension range in polyethylene tethering devices, such as the VersaTie (NuVasive) used in this study. Three specimens were instrumented to test tether tensions of 0, 75, and 150 Newtons (N) at L1-L2, T9-T10, and T3-T4. An optical tracking system was used to measure when specimens reached proximal junctional kyphosis, experienced instrumentation or tissue failure, or reached a cap of 2500 cycles. Radiographs were obtained before and after testing. RESULTS At all levels, use of a tether at tension forces of 75 N and 150 N elicited a protective effect. The only level in which a higher tension on the tether resulted in more protection was at T3-T4. When averaged, the use of a tether at tension forces of 75 N and 150 N showed 1000 cycles of protection at L1-L2, 2000 cycles at T9-T10, and 1426 cycles at T3-T4. Radiographic analysis corroborated these findings. CONCLUSIONS The use of a tether in a cadaveric model prevents the development of proximal junctional kyphosis across all tested levels and an increased tension force of 150 N is protective at the proximal thoracic spine. These data can be used to develop further models for a tether system that reproducibly applies a fixed tension force above the thoracolumbar rod construct.
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Affiliation(s)
- Mary Margaret O'Hehir
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Timothy E O'Connor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA; Marcus Neuroscience Institute, Boca Raton, Florida, USA
| | - Brandon L Mariotti
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - David W Polly
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.
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Jackson-Fowl B, Hockley A, Naessig S, Ahmad W, Pierce K, Smith JS, Ames C, Shaffrey C, Bennett-Caso C, Williamson TK, McFarland K, Passias PG. Adult cervical spine deformity: a state-of-the-art review. Spine Deform 2024; 12:3-23. [PMID: 37776420 DOI: 10.1007/s43390-023-00735-5] [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: 08/27/2020] [Accepted: 07/01/2023] [Indexed: 10/02/2023]
Abstract
Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.
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Affiliation(s)
- Brendan Jackson-Fowl
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Aaron Hockley
- Department of Neurosurgery, University of Alberta, Edmonton, AB, USA
| | - Sara Naessig
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Tyler K Williamson
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Kimberly McFarland
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
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Faulks CR, Biddau DT, Munday NR, McKenzie DP, Malham GM. Patient-specific spinal rods in adult spinal deformity surgery reduce proximal junctional failure: a review of patient outcomes and surgical technique in a prospective observational cohort. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:409-421. [PMID: 38196735 PMCID: PMC10772658 DOI: 10.21037/jss-23-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/22/2023] [Indexed: 01/11/2024]
Abstract
Background Spinal rods used for adult spinal deformity (ASD) correction are usually manufactured straight and bent manually during surgery. Pre-bent patient-specific spinal rods (PSSR) developed with software provide the surgeon with an intraoperative deformity correction consistent with the surgical plan. Our aim was to report clinical and radiological outcomes using PSSR. We investigated rates of junctional complications both proximally [kyphosis (PJK) and failure (PJF)] and distally [failure (DJF)]. Methods Prospective case series of 20 consecutive patients who underwent ≥4 level ASD surgery with PSSR at a single institution between January 2019 and December 2022. Preoperative, 6-week, 6-month, 12-month, 24-month, and final follow-ups assessed patient satisfaction (Ottawa decision regret questionnaire) and patient reported outcome measures (PROMs) [visual analogue scale (VAS; Back/Leg), Oswestry disability index (ODI), and 12-Item Short Form Survey (SF-12)]. Sagittal spinopelvic parameters [sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence and lumbar lordosis mismatch (PI-LL)] measured by serial EOS scans were performed preoperatively then compared to planned correction and postoperative measures. Interoperative cages (narrow/wide) were placed for interbody support. PJK risk score assessed likelihood of developing kyphosis. Serial computed tomography (CT) imaging assessed complication (fusion/subsidence). Results The mean age of the patients (75% female) was 71.9±6.9 years, and the mean follow-up was 25.2±8.6 [7-40] months. Preoperative mean PROMs showed statistically significant overall improvement (P<0.001) postoperatively to final follow-up. Four patients without wide footprint cages at L4/5 or L5/S1, suffered DJF and reported regret undergoing surgery. Statistically significant difference (P<0.001) between preoperative and surgical plan in SVA and PI-LL but not in PT (P=0.058). No statistically significant difference in surgical plan versus the postoperative SVA, PI-LL, and PT (due to difficulty achieving the surgical plan, and also to maintaining the correction). One patient suffered PJF. There was a mean proximal kyphotic angle (PKA) of 17.8±13.0 degrees and PJK risk score of 3.7±1.0 with 40% who experienced PJK. No rod breakages were observed. Conclusions In this series, PSSR improved PROMs and treated ASD. Sagittal parameters planned preoperatively correlated with postoperative correction. PJF was reduced, compared to the literature (35%), but PJK was observed over time. DJF occurred and was related to the absence of interbody cages at the lumbosacral junction and decisional regret.
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Affiliation(s)
- Charlie R. Faulks
- Neuroscience Institute, Epworth HealthCare, Melbourne, VIC, Australia
| | - Dean T. Biddau
- Neuroscience Institute, Epworth HealthCare, Melbourne, VIC, Australia
| | - Nigel R. Munday
- Neuroscience Institute, Epworth HealthCare, Melbourne, VIC, Australia
| | - Dean P. McKenzie
- Research Development & Governance, Epworth HealthCare, Melbourne, VIC, Australia
- Swinburne University of Technology, Melbourne, VIC, Australia
| | - Gregory M. Malham
- Neuroscience Institute, Epworth HealthCare, Melbourne, VIC, Australia
- Swinburne University of Technology, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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Shafiekhani P, Darabi M, Jajin EA, Shahmohammadi M. Pedicle Screw Fixation With Cement Augmentation Versus Without in the Treatment of Spinal Stenosis Following Posterior Spinal Fusion Surgery, Superiority According to Bone Mineral Density: A Three-Arm Randomized Clinical Trial. World Neurosurg 2023; 180:e266-e273. [PMID: 37741334 DOI: 10.1016/j.wneu.2023.09.050] [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: 07/09/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE To investigate whether cement augmentation has an impact on clinical and radiologic outcomes following posterior spinal fusion (PSF) in low-density bones and whether its performance is comparable to regular bone density. METHODS Between 2017 and 2021, 114 patients with spinal canal stenosis were enrolled to undergo PSF. They were initially stratified based on their bone mineral density: T-score ≥ -1.5: Group I (n = 34), and T-score < -1.5: Group II (n = 80). Furthermore, group II was randomly subdivided: II-A (unaugmented, n = 35) and II-B (bone cement augmented, n = 45). The primary and secondary endpoints of the study were evaluated using visual analog scales (VAS) and radiologic parameters, including screw loosening, screw or rod fractures, proximal junctional kyphosis (PJK), proximal junctional vertebral fracture (PJVF), and adjacent segment disease (ASD), at 1 year postoperatively. RESULTS All 3 groups showed improvement in VAS scores, but the most significant improvements were seen in groups I and II-B. Group II-B had lower incidence rates of ASD, PJVF, PJK, rod, and screw fracture compared to group II-A, but only screw loosening was statistically significant (P < 0.0001). Contrary, there were statistically significant differences in all variables except for ASD and screw fracture (P = 0.0576 and 0.670, respectively) when comparing groups I and II-A. In both groups I and II-A, screw loosening was the most common complication following PSF, while only 5.41% of patients in group II-B experienced it. CONCLUSIONS The efficacy of cement augmentation in mitigating pain and screw loosening following PSF surgery in low-density bones is comparable to that of normal-density bone.
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Affiliation(s)
- Paria Shafiekhani
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojtaba Darabi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elnaz Amanzadeh Jajin
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Shahmohammadi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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12
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Han IH. Commentary on "Development and Validation of an Online Calculator to Predict Proximal Junctional Kyphosis After Adult Spinal Deformity Surgery Using Machine Learning". Neurospine 2023; 20:1281-1283. [PMID: 38171295 PMCID: PMC10762415 DOI: 10.14245/ns.2347302.651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Affiliation(s)
- In Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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13
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Wang J, Chen Q, Ai Y, Huang Y, Zhu C, Ding H, Feng G, Liu L, Song Y. Vertebral bone quality score as a novel predictor of proximal junctional kyphosis after thoracic adolescent idiopathic scoliosis surgery. 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 2023; 32:3996-4002. [PMID: 37606725 DOI: 10.1007/s00586-023-07894-z] [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: 03/27/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Proximal junctional kyphosis (PJK) is one of the most common complications after thoracic AIS surgery. Previous studies reported that the etiology of PJK was associated with osteopenia and meanwhile the AIS patients were found osteopenia which could persist into adulthood. Recently, an MRI-based vertebral bone quality score (VBQ) was reported to be a promising tool which can assess preoperative bone quality. OBJECTIVE This study aims to evaluate the utility of VBQ score in predicting PJK after corrective surgery for thoracic AIS (Lenke 1 and 2). METHODS We conducted a retrospective study to identify the predictive efficiency of VBQ score for PJK in thoracic AIS patients. Demographic, radiographic parameters, and surgical variables were collected. VBQ score was calculated using preoperative T1-weighted MRI. Univariate analysis, linear regression, and multivariate logistic regression were performed to determine potential risk factors of PJK and correlation between other parameters and VBQ score. Receiver operating characteristic analysis and area under the curve values were utilized to evaluate the predictive efficiency of VBQ score for PJK. RESULTS A total of 206 patients (aged 14.4 ± 2.3 years) were included, of which 33 (16.0%) developed PJK. VBQ scores were significantly different between the PJK and non-PJK groups (2.8 ± 0.2 vs 2.5 ± 0.2, P < 0.01). A significant positive correlation was found between VBQ score and PJA (R2 = 0.1728, P < 0.01).On multivariate analysis, VBQ score was the only significant predictor of PJK (odds ratio = 2.178, 95% CI = 1.644-2.885, P < 0.001), with a predictive accuracy of 83%. CONCLUSION Higher VBQ scores were independently associated with PJK occurrence after corrective surgery for thoracic AIS. Preoperative measurement of VBQ score on MRI may serve as a valuable tool in planning thoracic AIS surgery.
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Affiliation(s)
- Juehan Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Qian Chen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
- Department of Orthopaedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Youwei Ai
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Yong Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Ce Zhu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Hong Ding
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Ganjun Feng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
| | - Limin Liu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China.
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Road, Chengdu, Sichuan, China
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14
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Donato Z, Lizardi J, Constantinescu D, Moore M, Kuczmarski A. Influential literature regarding proximal junctional kyphosis: A bibliometric review. J Orthop 2023; 43:48-56. [PMID: 37555203 PMCID: PMC10404860 DOI: 10.1016/j.jor.2023.07.013] [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: 06/26/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/10/2023] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE This bibliometric review summarizes the publication trends and critical information about the most cited Proximal Junction Kyphosis (PJK) articles. BACKGROUND Data: Proximal junctional kyphosis is frequently diagnosed after spinal fusion surgery. However, there continues to be heavy debate regarding the definition, incidence, risk factors, and treatment of this disorder. METHODS Nine hundred eleven articles were found when searching The Web of Science database with the keywords "Proximal junctional kyphosis" and "proximal junctional failure." The 200 top-cited articles were reviewed and screened to ensure PJK was discussed. The articles were filtered based on the highest to lowest number of citations, and the top 50 articles were chosen. Inclusion criteria included articles that contained a discussion of PJK and outcomes after surgery. Exclusion criteria included articles without mentioning PJK, or that studied non-human subjects. The 50 most cited articles were sorted by level of evidence and their classification for analysis. RESULTS The 50 most cited articles in this study were published a total of 6056 times. These articles were cited 71-413 times in the literature, with publications from 1994 to 2018. Most of the top 50 articles (64%) were published in the USA. Specifically, HSS and Washington University are the institutions with the most contributions to the publication of the most cited articles on PJK (n = 16). Lenke was the author that contributed to most publications in the top 50 articles on PJK. CONCLUSION This study provides a framework for the most cited articles published on PJK. Most articles on this topic were in the category of clinical outcomes (36%) and were of a level of evidence III (46%). Most of the top-cited articles came from the journal Spine (68%) and were published in the USA (64%). These top-cited papers are essential to understanding this critical trending topic in spine surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zachary Donato
- The University of Miami Leonard M. Miller School of Medicine, Department of Education, United States
| | - Juan Lizardi
- The University of Miami Leonard M. Miller School of Medicine, Department of Education, United States
| | | | - Maya Moore
- The University of Miami Leonard M. Miller School of Medicine, Department of Education, United States
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15
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Yagi M, Yamanouchi K, Fujita N, Funao H, Ebata S. Proximal Junctional Failure in Adult Spinal Deformity Surgery: An In-depth Review. Neurospine 2023; 20:876-889. [PMID: 37798983 PMCID: PMC10562237 DOI: 10.14245/ns.2346566.283] [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: 05/19/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 10/07/2023] Open
Abstract
Adult spinal deformity (ASD) surgery aims to correct abnormal spinal curvature in adults, leading to improved functionality and reduced pain. However, this surgery is associated with various complications, one of which is proximal junctional failure (PJF). PJF can have a significant impact on a patient's quality of life, necessitating a comprehensive understanding of its causes and the development of effective management strategies. This review aims to provide an in-depth understanding of PJF in ASD surgery. PJF is a complex complication resulting from a multitude of factors including patient characteristics, surgical techniques, and postoperative management. Age, osteoporosis, overcorrection of sagittal alignment, and poor bone quality are identified as significant risk factors. The clinical implications of PJF are substantial, often requiring revision surgery and causing a considerable decrease in patients' quality of life. Prevention strategies include careful preoperative planning, appropriate patient selection, and optimization of surgical techniques. Treatment often necessitates a multifaceted approach, including surgical intervention and the management of underlying risk factors. Predictive modeling is an emerging field that may offer a promising avenue for the risk stratification of patients and individualized preventive strategies. A thorough understanding of PJF's pathogenesis, risk factors, and clinical implications is essential for surgeons involved in ASD surgery. Current preventive measures and treatment strategies aim to mitigate the risk and manage the complications of PJF, but the complication cannot be entirely prevented. Future research should focus on the development of more effective preventive and treatment strategies, and predictive models could be valuable in this pursuit.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopaedic Surgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Kento Yamanouchi
- Department of Orthopaedic Surgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Naruhito Fujita
- Department of Orthopaedic Surgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, International University of Health and Welfare, School of Medicine, Narita, Japan
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16
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Lee BJ, Bae SS, Choi HY, Park JH, Hyun SJ, Jo DJ, Cho Y. Proximal Junctional Kyphosis or Failure After Adult Spinal Deformity Surgery - Review of Risk Factors and Its Prevention. Neurospine 2023; 20:863-875. [PMID: 37798982 PMCID: PMC10562224 DOI: 10.14245/ns.2346476.238] [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: 04/28/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 10/07/2023] Open
Abstract
Proximal junction kyphosis (PJK) is a common imaging finding after long-level fusion, and proximal junctional failure (PJF) is an aggravated form of the progressive disease spectrum of PJK. This includes vertebral fracture of upper instrumented vertebra (UIV) or UIV+1, instability between UIV and UIV+1, neurological deterioration requiring surgery. Many studies have reported on PJK and PJF after long segment instrumentation for adult spinal deformity (ASD). In particular, for spine deformity surgeons, risk factors and prevention strategies of PJK and PJF are very important to minimize reoperation. Therefore, this review aims to help reduce the occurrence of PJK and PJF by updating the latest contents of PJK and PJF by 2023, focusing on the risk factors and prevention strategies of PJK and PJF. We conducted a search on multiple database for articles published until February 2023 using the search keywords "proximal junctional kyphosis," "proximal junctional failure," "proximal junctional disease," and "adult spinal deformity." Finally, 103 papers were included in this study. Numerous factors have been suggested as potential risks for the development of PJK and PJF, including a high body mass index, inadequate postoperative sagittal balance and overcorrection, advanced age, pelvic instrumentation, and osteoporosis. Recently, with the increasing elderly population, sarcopenia has been emphasized. The quality and quantity of muscle in the surgical site have been suggested as new risk factor. Therefore, spine surgeon should understand the pathophysiology of PJK and PJF, as well as individual risk factors, in order to develop appropriate prevention strategies for each patient.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sung Soo Bae
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ho Young Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Yongjae Cho
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Korean Spinal Deformity Society (KSDS)
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
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Lafage R, Passias P, Sheikh Alshabab B, Bess S, Smith JS, Klineberg E, Kim HJ, Elysee J, Shaffrey C, Burton D, Hostin R, Mundis G, Schwab F, Lafage V. Patterns of Lumbar Spine Malalignment Leading to Revision Surgery for Proximal Junctional Kyphosis: A Cluster Analysis of Over- Versus Under-Correction. Global Spine J 2023; 13:1737-1744. [PMID: 35225013 PMCID: PMC10556910 DOI: 10.1177/21925682211047461] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Investigate the patterns of fused lumbar alignment in patients requiring revision surgery for proximal junctional kyphosis (PJK). METHODS Fifty patients (67.8 yo, 76% female) with existing thoraco-lumbar fusion (T10/12 to pelvis) and indicated for surgical correction for PJK were included. To investigate patterns of radiographic alignment prior to PJK revision, unsupervised 2-step cluster analysis was run on parameters describing the fused lumbar spine (PI-LL) to identify natural independent groups within the cohort. Clusters were compared in terms of demographics, pre-operative alignment, surgical parameters, and post-operative alignment. Associations between pre- and post-revision PJK angles were investigated using a Pearson correlation analysis. RESULTS Analysis identified 2 distinct patterns: Under-corrected (UC, n = 12, 32%) vs over-corrected (OC, n = 34, 68%) with a silhouette of .5. The comparison demonstrated similar pelvic incidence (PI) and PJK angle but significantly greater deformity for the UC vs OC group in terms of PI-LL, PI-LL offset, pelvic tilt, and sagittal vertebral axis. The surgical strategy for PJK correction did not differ between the 2 groups in terms of approach, American Society of Anesthesiologists grade, decompression, use of osteotomy, interbody fusion, or fusion length. The post-revision PJK angle significantly correlated with the amount of PJK correction within the OC group but not within the UC group. CONCLUSIONS This study identified 2 patterns of lumbar malalignment associated with severe PJK: over vs under corrected. Despite the difference in PJK etiology, both patterns underwent the same revision strategy. Future analysis should look at the effect of correcting focal deformity alone vs correcting focal deformity and underlying malalignment simultaneously on recurrent PJK rate.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Shay Bess
- Denver International Spine Center, Presbyterian St Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Gregory Mundis
- Department Of Orthopedics, Scripps Clinic, San Diego, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
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Erkilinc M, Coathup M, Liska MG, Lovevoy J. Can placement of hook at the upper instrumented level decrease the proximal junctional kyphosis risk in adolescent idiopathic scoliosis? 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 2023; 32:3113-3117. [PMID: 37284899 DOI: 10.1007/s00586-023-07803-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/01/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Proximal junctional kyphosis is a commonly encountered clinical and radiographic phenomenon after pediatric and adolescent spinal deformity surgery that may lead to postoperative deformity, pain, and dissatisfaction. The purpose of the study was to identify whether the placement of transverse process hooks is an effective way to prevent PJK. METHODS Adolescent idiopathic scoliosis patients who underwent posterior spinal fusion between November 2015 and May 2019 were retrospectively analyzed. A minimum 2-year follow-up was required. Demographic and surgical data included UIV level type of instrumentation (hook vs screw) were reported. Radiologic parameters included main curve Cobb angle, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), and proximal junctional angle (PJA) were assessed. Patients were divided into two groups based on the type of instrumentation at the UIV level whether placement of hook versus pedicle screw. RESULTS Three hundred and thirty-seven patients were included with the mean age 14.2 ± 1.9 years. Thirty patients (8.9%) were diagnosed with proximal junctional kyphosis radiographically. PJK incidence was found 3.2% (5/154) in the hook group and 13.3% (23/172) in the screw group and the difference found statistically significant. In the PJK group, preoperative thoracic kyphosis and the degree of kyphosis correction were also significantly higher than non-PJK patients. CONCLUSION Placement of transverse process hooks at the UIV level in posterior spinal fusion surgery for AIS patients was associated with decreased risk of PJK. A larger preoperative kyphosis and greater degree of kyphosis correction correlated with PJK.
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Affiliation(s)
- Mehmet Erkilinc
- Department of Orthopedics, Johns Hopkins University, Baltimore, MD, USA.
- Department of Orthopedics, Nemours Children's Hospital, 6535 Nemours Parkway, Orlando, FL, 32827, USA.
| | - Melanie Coathup
- Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, FL, USA
| | | | - John Lovevoy
- Department of Orthopedics, Nemours Children's Hospital, 6535 Nemours Parkway, Orlando, FL, 32827, USA
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Schömig F, Becker L, Schönnagel L, Völker A, Disch AC, Schnake KJ, Pumberger M. Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review. Global Spine J 2023; 13:52S-58S. [PMID: 37084355 PMCID: PMC10177307 DOI: 10.1177/21925682231159066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. METHODS We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. RESULTS Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. CONCLUSIONS As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.
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Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Luis Becker
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Schönnagel
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Völker
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center, University Center for Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Lower Hounsfield Units and Severe Multifidus Sarcopenia Are Independent Predictors of Increased Risk for Proximal Junctional Kyphosis and Failure Following Thoracolumbar Fusion. Spine (Phila Pa 1976) 2023; 48:223-231. [PMID: 36692154 DOI: 10.1097/brs.0000000000004517] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of the present study was to assess the impact of sarcopenia on the development of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following thoracolumbar spine fusion surgery using opportunistic evaluation of paraspinal fatty degeneration on preoperative magnetic resonance imaging. SUMMARY OF BACKGROUND DATA While paraspinal sarcopenia has been shown to have detrimental consequences following posterior cervicothoracic fusions, the impact of paraspinal sarcopenia on PJK and PJF following thoracolumbar spine fusion surgery remains unknown. MATERIALS AND METHODS We performed a retrospective review of patients who underwent posterior spine fusion surgery that extended caudally to the pelvis and terminated cranially between T10 and L2 between 2010 and 2017. The cohort was divided into three groups: (1) patients without PJK or PJF, (2) patients with PJK but no PJF, and (3) patients with PJF. Univariate and multivariate analyses were performed to determine risk factors for the development of proximal junctional complications. RESULTS We identified 150 patients for inclusion in this study. Mean Hounsfield Units at the upper instrumented vertebra (UIV) was 148.3±34.5 in the cohort of patients without PJK or PJF, which was substantially higher than values recorded in the PJK (117.8±41.9) and PJF (118.8±41.8) subgroups (P<0.001). Severe multifidus sarcopenia was identified at a much higher rate in the subgroups of patients who developed PJK (76.0%) and PJF (78.9%) than in the subgroup of patients who developed neither PJK nor PJF (34.0%; P<0.001). Multivariate analysis demonstrated both low HU at the UIV and moderate-severe multifidus sarcopenia to be risk factors for the development of PJK and PJF. CONCLUSION The results of this study suggest severe paraspinal sarcopenia and diminished bone density at the UIV impart an increased risk of developing PJK and PJF, while markers of systemic frailty such as modified Frailty Index and Charlson Comorbidity Index are not associated with an increased risk of these complications. LEVEL OF EVIDENCE III.
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21
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The postoperative course of mechanical complications in adult spinal deformity surgery. Spine Deform 2023; 11:175-185. [PMID: 36063294 DOI: 10.1007/s43390-022-00576-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/20/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE (a) Describe the time course of each mechanical complication, and (b) compare radiographic measurements and preoperative patient-reported outcome measures (PROMs) among each mechanical complication type. METHODS A single-institution case-control study was undertaken of patients undergoing adult spinal deformity (ASD) surgery from 2009-2017. Exposure variables included patient demographics, operative variables, radiographic measurements, and preoperative PROMs, including Oswestry Disability Index (ODI), Numeric Rating Scale Back/Leg-pain scores (NRS-Back/Leg), and EuroQol-5D (EQ-5D). The primary outcomes were occurrence of a mechanical complication and time to complication. Due to overlapping occurrence, rod fracture and pseudarthrosis were grouped into one composite category. RESULTS 145 patients underwent ASD surgery and were followed for at least 2 years. 30/47 (63.8%) patients with proximal junctional kyphosis (PJK) required reoperation, whereas 27/31 (87.1%) patients with pseudarthrosis/rod fracture required reoperation (63.8% vs. 87.1%, Χ2 = -0.23, 95% CI -0.41, -0.05, p = 0.023). Cox regression showed no significant difference in time to reoperation between PJK and rod fracture/pseudarthrosis (HR = 0.97, 95% CI 0.85-1.11, p = 0.686). Distal junctional kyphosis (DJK) (N = 3; 2 reoperation) and implant failures (N = 4; 0 reoperations) were rare. Patients with PJK had significantly lower Hounsfield Units preoperatively compared to those with pseudarthrosis/rod fracture (138.2 ± 43.8 vs. 160.3 ± 41.0, mean difference (MD) = -22.1, 95% CI -41.8, -2.4, p = 0.028), more prior fusions (51.1% vs. 25.8%, Χ2 = 0.253, 95% CI 0.41, 0.46, p = 0.026), fewer instrumented vertebrae (9.2 ± 2.6 vs. 10.7 ± 2.5, MD = -1.5, 95% CI -2.7, -0.31, p = 0.013), and higher postoperative thoracic kyphosis (TK) (46.3 ± 12.7 vs. 34.9 ± 10.6, MD = 11.4, 95% CI 5.9, 16.9, p < 0.001). Higher postoperative C7 sagittal vertical axis (SVA) did not achieve a significant difference (80.7 ± 72.1 vs. 51.9 ± 57.3, MD = 28.8, 95% CI -1.9, 59.5, p = 0.066). No differences were seen in preoperative PROMs. CONCLUSION Patients with pseudarthrosis/rod fracture had a higher reoperation rate compared to those with PJK with similar time to reoperation. Moreover, patients with PJK had higher postoperative TK, lower Hounsfield Units, more prior fusions, and fewer instrumented levels compared to those with pseudarthrosis/rod fracture. The results of this single-institution study suggest that even though mechanical complications are often analyzed as a single group, important differences may exist between them. LEVEL OF EVIDENCE III.
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22
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Rezvani M, Asadi J, Sourani A, Foroughi M, Tehrani DS. In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes. Korean J Neurotrauma 2023; 19:90-102. [PMID: 37051034 PMCID: PMC10083448 DOI: 10.13004/kjnt.2023.19.e9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 03/22/2023] Open
Abstract
Objective To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation. Methods This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes. Results A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications. Conclusions Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.
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Affiliation(s)
- Majid Rezvani
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jamalodin Asadi
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arman Sourani
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mina Foroughi
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Donya Sheibani Tehrani
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Kuo CC, Soliman MAR, Aguirre AO, Ruggiero N, Kruk M, Khan A, Ghannam MM, Almeida ND, Jowdy PK, Smolar DE, Pollina J, Mullin JP. Vertebral Bone Quality Score Independently Predicts Proximal Junctional Kyphosis and/or Failure After Adult Spinal Deformity Surgery. Neurosurgery 2022; 92:945-954. [PMID: 36700747 DOI: 10.1227/neu.0000000000002291] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) can be catastrophic complications associated with adult spinal deformity (ASD) surgery. These complications are markedly influenced by osteoporosis, leading to additional vertebral fracture and pedicle screw loosening. The MRI-based vertebral bone quality score (VBQ) is a newly developed tool that can be used to assess bone quality. OBJECTIVE To investigate the utility of the VBQ score in predicting PJK and/or PJF (PJF/PJK) after ASD correction. METHODS We conducted a retrospective chart review to identify patients age ≥50 years who had received ASD surgery of 5 or more thoracolumbar levels. Demographic, spinopelvic parameters, and procedure-related variables were collected. Each patient's VBQ score was calculated using preoperative T1-weighted MRI. Univariate analysis and multivariate logistic regression were performed to determine potential risk factors of PJK/PJF. Receiver operating characteristic analysis and area-under-the-curve values were generated for prediction of PJK/PJF. RESULTS A total of 116 patients were included (mean age, 64.1 ± 6.8 years). Among them, 34 patients (29.3%) developed PJK/PJF. Mean VBQ scores were 3.13 ± 0.46 for patients with PJK/PJF and 2.46 ± 0.49 for patients without, which was significantly different between the 2 groups ( P < .001). On multivariate analysis, VBQ score was the only significant predictor of PJK/PJF (odds ratio = 1.745, 95% CI = 1.558-1.953, P < .001), with a predictive accuracy of 94.3%. CONCLUSION In patients undergoing ASD correction, higher VBQ was independently associated with PJK/PJF occurrence. Measurement of VBQ score on preoperative MRI may be a useful adjunct to ASD surgery planning.
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Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.,Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Marissa Kruk
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Neil D Almeida
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - David E Smolar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
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24
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Validation of Age-adjusted Ideal Sagittal Alignment in Terms of Proximal Junctional Failure and Clinical Outcomes in Adult Spinal Deformity. Spine (Phila Pa 1976) 2022; 47:1737-1745. [PMID: 35917282 DOI: 10.1097/brs.0000000000004449] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To validate the age-adjusted ideal sagittal alignment in terms of proximal junctional failure (PJF) and clinical outcomes. SUMMARY OF BACKGROUND It is reported that optimal sagittal correction with regard to the age-adjusted ideal sagittal alignment reduces the risk of PJF development. However, few studies have validated this concept. The age-considered optimal correction is likely to be undercorrection in terms of conventional surgical target, such as pelvic incidence (PI)-lumbar lordosis (LL) within ±9°. Therefore, the clinical impact of age-adjusted sagittal alignment should be evaluated along with radiographic effect. MATERIALS AND METHODS Adult spinal deformity patients, aged 50 years and above, who underwent greater than or equal to four-level fusion to sacrum with a minimum of four years of follow-up data were included in this study. Radiographic risk factors for PJF (including age-adjusted ideal PI-LL) were evaluated with multivariate analyses. Three groups were created based on PI-LL offset between age-adjusted ideal PI-LL and actual actual PI-LL: undercorrection, ideal correction, and overcorrection. Clinical outcomes were compared among the three groups. RESULTS This study included 194 adult spinal deformity patients. The mean age was 68.5 years and there were 172 females (88.7%). PJF developed in 99 patients (51.0%) at a mean postoperative period of 14.9 months. Multivariate analysis for PJF revealed that only PI-LL offset group had statistical significance. The proportion of patients with PJF was greatest in the overcorrection group followed by the ideal correction and undercorrection groups. Overcorrected patients regard to the age-adjusted ideal alignment showed poorer clinical outcomes than the other patient groups. CONCLUSIONS Overcorrection relative to age-adjusted sagittal alignment increases the risk of PJF development and is associated with poor clinical outcomes. Older patients and those with small PI are likely to be overcorrected in terms of the age-adjusted PI-LL target. Therefore, the age-adjusted alignment should be considered more strictly in these patients.
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25
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Rahmani R, Sanda M, Sheffels E, Singleton A, Stegelmann SD, Kane B, Andreshak TG. The efficacy of prophylactic vertebroplasty for preventing proximal junctional complications after spinal fusion: a systematic review. Spine J 2022; 22:2050-2058. [PMID: 35944827 DOI: 10.1016/j.spinee.2022.07.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/19/2022] [Accepted: 07/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prophylactic vertebroplasty (VP) is performed at the upper level of instrumentation during spinal fusion to reduce the risk of proximal junctional kyphosis (PJK), proximal junctional fracture (PJFx), and proximal junctional failure (PJF). This study investigated the effect of VP on patient outcomes after spinal fusion. PURPOSE The aim of this systematic review was to evaluate the effect of prophylactic VP on the incidence of PJK in patients with spinal fusion. STUDY DESIGN/SETTING Level III, systematic review without meta-analysis. PATIENT SAMPLE Adult patients undergoing spinal fusion with VP. METHODS A PRISMA-compliant systematic literature review was conducted using PubMed/MEDLINE, Cochrane, and Embase. Included studies were published in English between January 1, 2001, and May 27, 2021, and reported primary data on adult patients undergoing spinal fusion with VP. Studies were excluded for insufficient surgical details; treatment for vertebral compression fracture; and case series and/or reports with <5 patients. The Newcastle-Ottawa Scale was used to assess risk of bias. The primary outcome of interest was PJK. Other outcomes included PJFx, PJF, and adverse events (eg, cement extravasation). Data were expressed as descriptive statistics. RESULTS Eight studies with 685 total patients (VP: 293 [42.8%]; No VP: 392 (57.2%)) were included. Five studies were comparative and three were single-arm. PJK incidence was reported in five studies (three comparatives, two single-arm) and ranged from 7.9% to 46.4%; incidence was lower in patients with VP in two of three (66.7%) comparative studies, and equal in one of three (33.3%). PJFx was reported in five studies (four comparatives, one single-arm) and ranged from 0.0% to 39.3%; incidence was lower in the VP group in two of four (50.0%) comparative studies, equal in one of four (25.0%), and higher in one of four (25.0%). PJF was reported in five studies (three comparatives, two single-arm) and ranged from 0.0% to 39.3%; incidence was lower in the VP group in two of three (66.7%) comparative studies and equal in one of three (33.3%). Cement extravasation was reported by four studies and ranged from 0% (0/36) to 48.3% (57/118) in patients with prophylactic VP. CONCLUSIONS Evidence on whether prophylactic VP decreases the incidence of PJK, PJFx, and PJF after spinal fusion is inconclusive and conflicting. Additionally, the risk of cement extravasation following prophylactic VP could not be evaluated due to insufficient evidence. Further research is needed to determine whether VP has a significant impact on patient outcomes and risks.
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Affiliation(s)
- Roman Rahmani
- Mercy Health St. Vincent Medical Center, Orthopedic Surgery Department, 2409 Cherry St, Toledo, OH, USA 43608
| | - Milo Sanda
- Mercy Health St. Vincent Medical Center, Orthopedic Surgery Department, 2409 Cherry St, Toledo, OH, USA 43608
| | - Erin Sheffels
- Superior Medical Experts, P.O. Box 600545, 1425 Minnehaha Ave E, St. Paul, MN, USA 55106
| | - Amy Singleton
- Mercy Health St. Vincent Medical Center, Orthopedic Surgery Department, 2409 Cherry St, Toledo, OH, USA 43608.
| | - Samuel D Stegelmann
- Mercy Health St. Vincent Medical Center, Orthopedic Surgery Department, 2409 Cherry St, Toledo, OH, USA 43608
| | - Bernadette Kane
- Superior Medical Experts, P.O. Box 600545, 1425 Minnehaha Ave E, St. Paul, MN, USA 55106
| | - Thomas G Andreshak
- Mercy Health St. Vincent Medical Center, Orthopedic Surgery Department, 2409 Cherry St, Toledo, OH, USA 43608
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26
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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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27
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Raj A, Lee CS, Park JS, Kang BJ, Shin TS, Park SJ. Characteristics of patients undergoing revision surgery for proximal junctional failure after adult spinal deformity surgery: revalidation of the Hart-International Spine Study Group proximal junctional kyphosis severity scale. J Neurosurg Spine 2022; 37:402-409. [PMID: 35334467 DOI: 10.3171/2022.2.spine211387] [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: 10/31/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Score on the proximal junctional kyphosis severity scale (PJKSS) has been validated to show good correlations with likelihood of revision surgery for proximal junctional failure (PJF) after surgical treatment of adult spinal deformity (ASD). However, if the patient has progressive neurological deterioration, revision surgery should be considered regardless of severity based on PJKSS score. This study aimed to revalidate the correlation of PJKSS score with likelihood of revision surgery in patients with PJF but without neurological deficit. In addition, the authors provide the cutoff score on PJKSS that indicates need for revision surgery. METHODS A retrospective study was performed. Among 360 patients who underwent fusion of more than 4 segments including the sacrum, 83 patients who developed PJF without acute neurological deficit were included. Thirty patients underwent revision surgery (R group) and 53 patients did not undergo revision surgery (NR group). All components of PJKSS and variables other than those included in PJKSS were compared between groups. The cutoff score on PJKSS that indicated need for revision surgery was calculated with receiver operating characteristic curve analysis. Multivariate analysis with logistic regression was performed to identify which variables were most predictive of revision surgery. RESULTS The mean patient age at the time of index surgery was 69.4 years, and the mean fusion length was 6.1 segments. All components of PJKSS, such as focal pain, instrumentation problem, change in kyphosis, fracture at the uppermost instrumented vertebra (UIV)/UIV+1, and level of UIV, were significantly different between groups. The average total PJKSS score was significantly greater in the R group than in the NR group (6.0 vs 3.9, p < 0.001). The calculated cutoff score was 4.5, with 70% sensitivity and specificity. There were no significant between-group differences in patient, surgical, and radiographic factors (other than the PJKSS components). Three factors were significantly associated with revision surgery on multivariate analysis: instrumentation problem (OR 8.160, p = 0.004), change in kyphosis (OR 4.809, p = 0.026), and UIV/UIV+1 fracture (OR 6.462, p = 0.002). CONCLUSIONS PJKSS score positively predicted need for revision surgery in patients with PJF who were neurologically intact. The calculated cutoff score on PJKSS that indicated need for revision surgery was 4.5, with 70% sensitivity and specificity. The factor most responsible for revision surgery was bony failure with > 20° focal kyphotic deformity. Therefore, early revision surgery should be considered for these patients even in the absence of neurological deficit.
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28
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Murata K, Fujibayashi S, Otsuki B, Shimizu T, Matsuda S. Risk Factors for Proximal Junctional Kyphosis in Fusions from the Sacrum to L1 or L2 for Adult Spinal Deformity. Spine Surg Relat Res 2022; 6:395-401. [PMID: 36051685 PMCID: PMC9381084 DOI: 10.22603/ssrr.2021-0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/11/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction Several targets have been proposed to achieve satisfactory alignment and favorable outcomes in adult spinal deformity surgery. Stopping the upper instrumented vertebra (UIV) at the thoracolumbar junction levels, especially between T11 and L1, is considered a high-risk factor for the development of proximal junctional kyphosis (PJK). Nevertheless, it is unknown in which patients the results of surgery are satisfactory when L1 or L2 is set as UIV with lumbosacral fixation. This study aimed to identify the risk factors for PJK in patients with lumbosacral fixation with L1 or L2 as UIV. Methods From January 2011 to December 2019, 21 consecutive patients who underwent lumbopelvic fixation for adult spinal deformity were included. The patients were divided into two groups: the PJK group (n=7) and the nonPJK group (n=14). Patients who experienced PJK within half a year of surgery were included in the PJK group. Pelvic incidence (PI), lumbar lordosis (LL), pelvic tilt (PT), thoracic kyphosis (TK), thoracic compensation (TK compensation), sagittal vertical axis (SVA), T10-L2 angle, and T1 pelvic angle (TPA) were measured before and after surgery. Results No difference was found between the two groups in terms of age and sex at the time of surgery. The indices that were significantly different between the two groups were preoperative PT, PI minus LL, TK, TPA, TK compensation, and postoperative T10-L2 angle. No significant differences were found in postoperative LL, PI minus LL, PT, TK, TPA, or SVA. Conclusions Preoperative X-ray indices, including preoperative TPA, TK compensation, TK, PT, and PI-LL, determined the risk of PJK in fusions from the sacrum to L1 or L2. Appropriate patient selection is crucial for the success of this surgery.
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Affiliation(s)
- Koichi Murata
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine
| | | | - Bungo Otsuki
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine
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Prasse T, Hofstetter CP, Heck VJ, Meyer C, Wetsch WA, Scheyerer MJ, Eysel P, Bredow J. Current Evidence on where to End a Fusion within the Thoracolumbar Junction Most Preferably - A Systematic Literature Review. Neurochirurgie 2022; 68:648-653. [PMID: 35817090 DOI: 10.1016/j.neuchi.2022.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
Proximal junctional kyphosis (PJK) is one main complication in the surgical treatment of adult spinal deformities. Ending within the thoracolumbar junction (TLJ) should but cannot always be avoided to reduce the risk for PJK. With this systematic review we sought to define the most preferable vertebra within the TLJ to minimize the risk for PJK and establish recommendations based on our findings. We conducted a systematic literature review by scanning the MEDLINE database in accordance with the PRISMA criteria. All articles addressing primary long-distance dorsal thoracolumbar fusion of at least three segments to treat adult spinal deformities were included. 1385 articles were identified and three were included to this review. The first study showed significantly higher rates of PJK in patients where the construct was extended to T7 or higher when compared to an ending at T11 to L1. The second article stated that an expansion to the TLJ resulted in significantly less surgical revisions due to PJK reduction. On the other hand, the third article found that a fusion of the whole thoracic spine reduces the PJK incidence postoperatively. Even though the most favorable vertebra within the TLJ to avoid PJK best could not yet be determined, our study identifies several principles that represent the current state of evidence for surgical treatment of adult scoliosis. Proper preoperative decision making based on thorough analysis and interpretation of the patient's sagittal alignment parameters can improve the individual outcome critically.
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Affiliation(s)
- T Prasse
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Kerpener Street 62, 50937 Cologne, Germany.
| | - C P Hofstetter
- University of Washington, Department of Neurological Surgery, 1959 NE Pacific Street, 98195 Seattle, USA
| | - V J Heck
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Kerpener Street 62, 50937 Cologne, Germany
| | - C Meyer
- Center for Spinal Surgery, Helios Klinikum Bonn/Rhein-Sieg, Von-Hompesch-Straße 1, 53123 Bonn, Germany
| | - W A Wetsch
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anesthesiology and Intensive Care, Kerpener Street 62, 50937 Cologne, Germany
| | - M J Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Kerpener Street 62, 50937 Cologne, Germany
| | - P Eysel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Kerpener Street 62, 50937 Cologne, Germany
| | - J Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Urbacher Weg 19, 51149 Cologne, Germany
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Vercoulen TFG, Doodkorte RJP, Roth A, de Bie R, Willems PC. Instrumentation Techniques to Prevent Proximal Junctional Kyphosis and Proximal Junctional Failure in Adult Spinal Deformity Correction: A Systematic Review of Clinical Studies. Global Spine J 2022; 12:1282-1296. [PMID: 34325554 PMCID: PMC9210240 DOI: 10.1177/21925682211034500] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To summarize the results of clinical studies investigating spinal instrumentation techniques aiming to reduce the postoperative incidence of proximal junctional kyphosis (PJK) and/or failure (PJF) in adult spinal deformity (ASD) patients. METHODS EMBASE and Medline® were searched for articles dating from January 2000 onward. Data was extracted by 2 independent authors and methodological quality was assessed using ROBINS-I. RESULTS 18 retrospective- and prospective cohort studies with a severe or critical risk of bias were included. Different techniques were applied at the upper instrumented vertebra (UIV): tethers in various configurations, 2-level prophylactic vertebroplasty (2-PVP), transverse process hooks (TPH), flexible rods (FR), sublaminar tapes (ST) and multilevel stabilization screws (MLSS). Compared to a pedicle screw (PS) group, significant differences in PJK incidence were found using tethers in various configurations (18% versus 45%, P = 0.001, 15% versus 38%, P = 0.045), 2-PVP (24% vs 36%, P = 0.020), TPH (0% vs. 30%, P = 0.023) and FR (15% versus 38%, P = 0.045). Differences in revision rates for PJK were found in studies concerning tethers (4% versus 18%, P = 0.002), 2-PVP (0% vs 13%, P = 0.031) and TPH (0% vs 7%, P = n.a.). CONCLUSION Although the studies are of low quality, the most frequently studied techniques, namely 2-PVP as anterior reinforcement and (tensioned) tethers or TPH as posterior semi-rigid fixation, show promising results. To provide a reliable comparison, more controlled studies need to be performed, including the use of clinical outcome measures and a uniform definition of PJF.
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Affiliation(s)
- Timon F. G. Vercoulen
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands,Timon F. G. Vercoulen, Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Remco J. P. Doodkorte
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alex Roth
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob de Bie
- Department of Epidemiology, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul C. Willems
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
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Tan SWH, Goh GS, Jiang L, Soh RCC. Do the benefits of hook-hybrid construct justify their use over all-pedicle screws constructs in maintaining postoperative curve correction for adolescent idiopathic scoliosis patients from an Asian population? Spine Deform 2022; 10:865-871. [PMID: 35258845 DOI: 10.1007/s43390-022-00493-w] [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: 11/03/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE (1) Compare outcomes of all-pedicle screws (PS) and hook-hybrid (H) constructs in adolescent idiopathic scoliosis (AIS) patients; and (2) investigate whether BMI, height or pedicle size may modify the effect of the type of surgical construct on the extent of curve decompensation. METHODS AIS patients who underwent surgical fixation with H or PS constructs at a single tertiary institution were reviewed. Patients with implant density of at least 70% and 2-year follow-up were included. Demographic and perioperative data collected were age, sex, height, BMI, implant density and pedicle diameter. Cobb's angles and curve correction were compared preoperatively, postoperatively and at follow-up. RESULTS In total, 59 patients were included. H group had a lower pedicle size at the highest level of construct and at T4 compared to PS group. Postoperatively, H group (30.2° ± 11.7°) and PS group (32.1° ± 10.4°) had similar correction (mean diff. 2.0°, p = 0.516). At 2-year follow-up, H group (1.6° ± 3.5°) and PS group (0.1° ± 2.8°) had similar curve deterioration (mean diff. 1.5°, p = 0.079). Uni- and multivariate analyses revealed that BMI and height were not associated with curve deterioration at 2-year follow-up among the H and PS groups. CONCLUSION H constructs provided similar maintenance of curve correction at 2-year follow-up compared to PS constructs. BMI and Stature did not modify curve deterioration between both groups at follow-up. This study supports the use of H constructs when faced with difficult pedicle morphology associated with shorter stature as it provides comparable and satisfactory long-term maintenance of curve correction. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Samuel Wei Han Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore.
| | - Graham S Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Lei Jiang
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Reuben Chee Cheong Soh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
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Postoperative and Intraoperative Cement Augmentation for Spinal Fusion. World Neurosurg 2022; 160:e454-e463. [PMID: 35051634 DOI: 10.1016/j.wneu.2022.01.046] [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: 11/10/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review outcomes of patients undergoing spinal fusion with prophylactic cement augmentation (CA) of pedicle screws and adjacent levels. METHODS In a retrospective case-control study, 59 patients underwent CA of pedicle screws for spinal fusion between 2003 and 2018. Most patients (83%) underwent postoperative CA, while 17% underwent intraoperative CA. Outcomes of CA techniques were compared, and patients undergoing CA for a thoracolumbar fusion (n = 51) were compared with a cohort not undergoing CA (n = 39). Mean follow-up was 3 years. RESULTS In patients receiving CA, survivorship free of proximal junctional kyphosis (PJK) was 94%, 60%, and 20% at 2, 5, and 10 years postoperatively. Survivorship free of revision was 95%, 83%, and 83% at 2, 5, and 10 years postoperatively. Development of PJK (P = 0.02, odds ratio [OR] 24.44) was associated with revision surgery. There were 4 (7%) cardiopulmonary complications. Patients who received CA for thoracolumbar fusion were older (70 years vs. 65 years) and were more likely to have osteoporosis (53% vs. 5%) than patients who did not receive CA. CA was associated with a decreased risk of PJK (P = 0.009, OR 0.16), while osteoporosis (P = 0.05, OR 4.10) and fusion length ≥8 levels (P = 0.06, OR 2.65) were associated with PJK. PJK was associated with revision surgery (P = 0.006, OR 12.65). CONCLUSIONS CA allows for substantial rates of radiographic PJK; however, this typically does not result in a need for revision surgery and leads to revision and PJK rates that are comparable to patients undergoing long segment fusions without osteoporosis.
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Proximal Junction Kyphosis in Adult Scoliosis: Best Postoperative Radiological Predictors-A Retrospective Cohort Study. Adv Orthop 2022; 2022:9814416. [PMID: 35371570 PMCID: PMC8967590 DOI: 10.1155/2022/9814416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Proximal junction kyphosis (PJK) is the postsurgical radiographic event seen in the surgical plane after the fusion of a spinal deformity. Unfavorable health outcomes have been reported in symptomatic PJK patients compared to non-PJK patients. Methods The data for adult scoliosis patients who underwent curve correction were extracted from the hospital database. Pelvic and spinal parameters were measured and calculated to compare four predictive formulae for occurrences of PJK. Formula 1. Restoration of hypothetical values of lumbar lordosis (LL) and thoracic kyphosis (TK) according to pelvic incidence (PI). Formula 2. Evaluation of global sagittal alignment. Formula 3. Restoration of the apex of LL to its hypothetical position according to the spine shape. Formula 4. Evaluation of positive-sum and negative-sum of (LL + TK). Results A total number of cases were 52. There were 14 cases of PJK. The incidence of PJK was 26.9%, and the mean age for PJK cases was 63.2 ± 5.2. The excellent predictor for occurrences of PJK was formula 3. Postsurgical sagittal apexes of lumbar lordosis were located in their hypothetical position in 24 cases, and 12.5% of these cases developed PJK. While sagittal apexes were not located in their hypothetical position in 28 patients, PJK occurred in 39.3% of them (P=0.03, OR: 4.53, (95% CI: 1.09–18.9)). The second good predictor for occurrences of PJK was formula 2 (GSA >45° versus GSA <45° OR = 2.5, (95% CI: 0.67–9.38), P=0.17). The other two formulae (1 and 4) were not good predictors for occurrences of PJK. Conclusion Among the four proposed formulae for predicting occurrences of PJK, the position of the sagittal apex of lumbar lordosis is an excellent predictor of the development of PJK, followed by GSA. Hypothetical values of LL and TK, and positive or negative-sum of (LL + TK), are weak predictors for occurrences of PJK.
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Borgeaud T, Le Huec JC, Faundez A. Pelvic and spinal postural changes between standing-sitting positions following lumbosacral fusion: a pilot study. INTERNATIONAL ORTHOPAEDICS 2022; 46:1839-1846. [PMID: 35266032 PMCID: PMC9349097 DOI: 10.1007/s00264-022-05365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
Purpose Prospective pre-operative and post-operative comparative analysis of radiographic spino-pelvic parameters between sitting versus standing positions of patients with LS fusion, to detect adaptation mechanisms around fused spinal segments. Methods Sixteen patients aged 53.9 ± 15.9 who underwent LS fusion between L3 and S1 were extracted from the database of an ongoing prospective study. Different spino-pelvic parameters were evaluated on full spine X-rays, standing, then sitting straight. Parameters were compared pre-operative versus post-operative, and on standing versus sitting X-rays. Results Preliminary results revealed a significantly greater pre-operative pelvic tilt (PT) in sitting than standing posture, (p = 0.020) but not in post-operative (p = 0.087). After surgery, PT was lower in sitting compared to pre-operative (p = 0.034) but not in standing (p = 0.245). L4–S1 lordosis was lower in sitting than standing in pre-operative (p = 0.014) and post-operative (p = 0.021). Surgery decreased segmental lordosis above the fusion (PSL, proximal sagittal lordosis) in sitting (p = 0.039) but not in standing (p = 0.193). No significant differences in thoracic kyphosis (TK) were observed. Fusions down to L5 versus S1 showed no significant differences for PT and PSL, neither in sitting versus standing, nor pre-operative versus post-operative. Conclusion Before fusion, compared to standing, PT increases in sitting straight posture (pelvic retroversion), and the lumbar spine adapts by decreasing its lordosis, mainly at L4–S1. After fusion, the segments adjacent to the instrumented section, adapt in flexion at lumbosacral and thoracolumbar junctions, i.e. just below and above (PSL). This might have mechanical implications for the occurrence of adjacent segment disease.
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Affiliation(s)
- Thomas Borgeaud
- Faculty of Medicine, Université de Genève (UNIGE), Rue Michel-Servet 1, 1206, Geneva, Switzerland
| | - Jean-Charles Le Huec
- Polyclinique Bordeaux Nord, Centre Vertebra, 15 rue Boucher, 33000, Bordeaux, France
| | - Antonio Faundez
- Hôpital de La Tour, Av. J.-D.-Maillard 3, 1217, Meyrin, Switzerland. .,Department of Surgery, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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Lafage R, Smith JS, Elysee J, Passias P, Bess S, Klineberg E, Kim HJ, Shaffrey C, Burton D, Hostin R, Mundis G, Ames C, Schwab F, Lafage V. Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine Deform 2022; 10:121-131. [PMID: 34460094 DOI: 10.1007/s43390-021-00397-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane. METHOD A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated. RESULTS 409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total. CONCLUSION Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA.
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Sacramento, Davis, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
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Passias PG, Bortz C, Pierce KE, Kummer NA, Lafage R, Diebo BG, Line BG, Lafage V, Burton DC, Klineberg EO, Kim HJ, Daniels AH, Mundis GM, Protopsaltis TS, Eastlack RK, Sciubba DM, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery. Spine (Phila Pa 1976) 2021; 46:1437-1447. [PMID: 33710114 DOI: 10.1097/brs.0000000000004033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospective cervical deformity (CD) database. OBJECTIVE Identify factors associated with distal junctional kyphosis (DJK); assess differences across DJK types. SUMMARY OF BACKGROUND DATA DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types. METHODS Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences. RESULTS Included: 136 CD patients (61 ± 10 yr, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both P < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (P = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than nonsevere (all P < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all P < 0.03) than static. Each type had varying associated factors. CONCLUSION Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Katherine E Pierce
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Nicholas A Kummer
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Breton G Line
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, CA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | | | | | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shay Bess
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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Faundez AA, Tsoupras A, Le Huec JC. Rationale and techniques for Posterior Opening Wedge Osteotomy (POWO) in proximal junctional failure due to iatrogenic lumbar hyperlordosis. Orthop Traumatol Surg Res 2021; 107:102657. [PMID: 32778438 DOI: 10.1016/j.otsr.2020.04.015] [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: 08/15/2019] [Revised: 04/05/2020] [Accepted: 04/14/2020] [Indexed: 02/03/2023]
Abstract
Proximal junctional kyphosis (PJK) is a compensatory phenomenon in reaction to pathologic lumbar hyperlordosis. Inappropriate spinal curve harmony incurs risk of PJK. Postoperative failure of posterior instrumentation, with kyphosis resistant to revision surgery at the proximal junction, may be caused by excessive iatrogenic lumbar lordosis. The surgical attitude should be to decrease lumbar lordosis by posterior opening wedge osteotomy (POWO). We describe the rationale for POWO and surgical techniques at L3. The technique is illustrated by a case report at 24 months' follow-up. Based on rational analysis of the distribution of lordosis along the lumbar spine and of adaptation of the sitting position, POWO may be indicated to avoid PJK after revision surgery in adult spinal Deformation revision surgery.
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Affiliation(s)
- Antonio A Faundez
- Orthopaedic Surgery Division, Department of Surgery, Geneva University Hospitals, Hôpital La Tour Meyrin, 4, rue Perret-Gentil, 1211 Geneva, Switzerland.
| | - Andreas Tsoupras
- Orthopaedic Surgery Division, Department of Surgery, Geneva University Hospitals, Hôpital La Tour Meyrin, 4, rue Perret-Gentil, 1211 Geneva, Switzerland
| | - Jean-Charles Le Huec
- Polyclinique Bordeaux Nord, Centre Vertebra, 15, rue Boucher, 33000 Bordeaux, France
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Park SJ, Park JS, Nam YJ, Choi YT, Lee CS. The Long-term Fate of Asymptomatic Proximal Junctional Kyphosis Following Long Instrumented Fusion in Elderly Patients with Sagittal Imbalance. Spine (Phila Pa 1976) 2021; 46:E1097-E1104. [PMID: 33710109 DOI: 10.1097/brs.0000000000004027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to investigate the long-term fate of asymptomatic PJK focusing on the elderly patients with sagittal imbalance by comparing the patients with and without PJK. SUMMARY OF BACKGROUND DATA Most of previous studies demonstrated that PJK does not negatively affect the clinical outcome compared to that of the patients without PJK. The question "will the asymptomatic PJK remain asymptomatic even in long-term follow-up?" has not been answered yet because the previous results were based on the short follow-up duration. METHODS Patients >60 years who underwent four or more level fusions to the sacrum for sagittal imbalance were followed up for >5 years. The radiographic and clinical outcomes were compared between PJK (n = 30) and non-PJK groups (n = 43). PJK was defined by proximal junctional angle (PJA) >10°. Only patients with >3 years of follow-up duration after PJK development were included in PJK group. The clinical outcome measures included visual analog scale (VAS) for the back and leg, Oswestry disability index (ODI), and Scoliosis Research Society (SRS)-22 scores. RESULTS The mean age was 69.2 years. Total follow-up duration was 92.4 months. Time between PJK development and the last follow-up was 67.4 months in PJK group. Although there were no differences between the two groups in terms of pelvic incidence-lumbar lordosis mismatch, pelvic tilt, or sacral vertical axis, PJA significantly increased from 6.5° postoperatively to 21.2° at the final follow-up in the PJK group. The clinical outcomes were worse (such as VAS for the back, ODI, and SRS-22 scores) in the PJK group than in non-PJK group, except for the satisfaction domain. Three (10%) of 30 patients underwent a revision surgery for PJK progression. CONCLUSION Even if PJK was asymptomatic at initial development, it progressed radiographically with time and eventually gave a negative impact on the clinical outcomes in long-term follow-up.Level of Evidence: 3.
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Affiliation(s)
- Se-Jun Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Rabinovich EP, Buell TJ, Sardi JP, Lazaro BCR, Shaffrey CI, Smith JS. A Novel Weave Tether Technique for Proximal Junctional Kyphosis Prevention in 71 Adult Spinal Deformity Patients: A Preliminary Case Series Assessing Early Complications and Efficacy. Oper Neurosurg (Hagerstown) 2021; 21:393-399. [PMID: 34467979 DOI: 10.1093/ons/opab305] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) rates may be as high as 69.4% after adult spinal deformity (ASD) surgery. PJK is one of the greatest unsolved challenges in long-segment fusions for ASD and remains a common indication for costly and impactful revision surgery. Junctional tethers may help to reduce the occurrence of PJK by attenuating adjacent-segment stress. OBJECTIVE To report our experience and assess early safety associated with a novel "weave-tether technique" (WTT) for PJK prophylaxis in a large series of patients. METHODS This single-center retrospective study evaluated consecutive patients who underwent ASD surgery including WTT between 2017 and 2018. Patient demographics, operative details, standard radiographic measurements, and complications were analyzed. RESULTS A total of 71 patients (mean age 66 ± 12 yr, 65% women) were identified. WTT included application to the upper-most instrumented vertebrae (UIV) + 1 and UIV + 2 in 38(53.5%) and 33(46.5%) patients, respectively. No complications directly attributed to WTT usage were identified. For patients with radiographic follow-up (96%; mean duration 14 ± 12 mo), PJK occurred in 15% (mean 1.8 ± 1.0 mo postoperatively). Proximal junctional angle increased an average 4° (10° to 14°, P = .004). Rates of symptomatic PJK and revision for PJK were 8.8% and 2.9%, respectively. CONCLUSION Preliminary results support the safety of the WTT for PJK prophylaxis. Approximately 15% of patients developed radiographic PJK, no complications were directly attributed to WTT usage, and the revision rate for PJK was low. These early results warrant future research to assess longer-term efficacy of the WTT for PJK prophylaxis in ASD surgery.
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Affiliation(s)
- Emily P Rabinovich
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Juan P Sardi
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bruno C R Lazaro
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Ha KY, Kim EH, Kim YH, Jang HD, Park HY, Cho CH, Cho RK, Kim SI. Surgical outcomes for late neurological deficits after long segment instrumentation for degenerative adult spinal deformity. J Neurosurg Spine 2021:1-7. [PMID: 34243161 DOI: 10.3171/2020.12.spine20604] [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: 04/16/2020] [Accepted: 12/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The most catastrophic symptom of proximal junctional failure (PJF) following long instrumented fusion surgery for adult spinal deformity (ASD) is neurological deficits. Although previous reports have shown that PJF usually developed during the early postoperative period, some patients showed late neurological deficits. The aim of this study was to report the incidence, characteristics, and surgical outcomes of PJF with late neurological deficits. METHODS Patients surgically treated for ASD at a single institution were retrospectively reviewed. Among them, the patients requiring revision surgery for newly developed neurological deficits at least 6 months after the initial surgery were included. Patient demographic, radiographic, surgical, and clinical data were investigated. Neurological status was assessed using the Frankel grading system. RESULTS PJF with late neurological deficits developed in 18 of 385 patients (4.7%). The mean age at the onset of neurological deficits was 72.0 ± 6.0 years, and the median time from the initial surgery was 4.5 years. The most common pathology of PJF was adjacent disc degeneration and subsequent canal stenosis (11 patients). Five patients showed disc degeneration with aseptic bone destruction. Fractures at the upper instrumented vertebra (UIV), UIV + 1, and UIV + 2 occurred in 2, 3, and 2 patients, respectively. Ossification of the yellow ligament, which had not been found at the first surgery, was identified in 6 patients. Eight patients showed improvement of their neurological deficits and 10 patients showed no improvement by the final follow-up. Perioperative major complications occurred in 8 of 18 patients. CONCLUSIONS The incidence of PJF with late neurological deficits following ASD surgery was 4.7% in this cohort. The patients showed several morphological features. After revision surgery, perioperative complications were common and the prognosis for improved neurological status was not favorable.
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Affiliation(s)
- Kee-Yong Ha
- 1Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul
| | - Eung-Ha Kim
- 2Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do
| | - Young-Hoon Kim
- 3Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
| | - Hae-Dong Jang
- 2Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do
| | - Hyung-Youl Park
- 4Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Hee Cho
- 3Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
| | - Ryu-Kyoung Cho
- 3Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
| | - Sang-Il Kim
- 3Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
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Diebo BG, Sheikh B, Freilich M, Shah NV, Redfern JAI, Tarabichi S, Shepherd EM, Lafage R, Passias PG, Najjar S, Schwab FJ, Lafage V, Paulino CB. Osteoporosis and Spine Surgery: A Critical Analysis Review. JBJS Rev 2021; 8:e0160. [PMID: 33006455 DOI: 10.2106/jbjs.rvw.19.00160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite being part of the aging process, early and adequate management of osteoporosis mitigates adverse outcomes associated with low bone mineral density. Although the health-care burden of osteoporosis is on the rise, screening and management of osteoporosis are not yet an integral part of preoperative patient evaluation in spine surgery. Patients with osteoporosis should undergo multidisciplinary evaluation and management, including lifestyle modifications and initiation of multiple therapeutic modalities. Integrating osteoporosis in preoperative optimization and surgical planning for patients undergoing spine surgery has the potential to mitigate osteoporosis-related postoperative complications.
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Affiliation(s)
- Bassel G Diebo
- 1Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York 2Royal College of Surgeons in Ireland (RCSI)-Bahrain, Al Sayh, Bahrain 3Division of Spine Surgery, Methodist Hospitals, Merrillville, Indiana 4Spine Service, Hospital for Special Surgery, New York, NY 5Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 6Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Mikula AL, Fogelson JL, Lakomkin N, Flanigan PM, Pinter ZW, Doan MK, Bydon M, Nassr A, Freedman B, Sebastian AS, Abode-Iyamah K, Anderson PA, Elder BD. Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction. Oper Neurosurg (Hagerstown) 2021; 21:270-275. [PMID: 34171907 DOI: 10.1093/ons/opab236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Low bone mineral density (BMD) on dual energy x-ray absorptiometry (DXA) is likely a risk factor for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, prior instrumentation and degenerative changes can preclude a lumbar BMD measurement. Hounsfield units (HU) represent an alternative method to estimate BMD via targeted measurements at the intended operative levels. OBJECTIVE To determine if patients with lower HU at the upper instrumented vertebrae (UIV) and vertebral body superior to the UIV (UIV + 1) are at greater risk for PJK and PJF. METHODS A retrospective chart review identified patients at least 50 yr of age who underwent instrumented lumbar fusion with pelvic fixation, a UIV from T10 to L2, and a preoperative computed tomography (CT) encompassing the UIV. HU were measured at the UIV, UIV + 1, and the L3-L4 vertebral bodies. RESULTS A total of 150 patients (80 women and 70 men) were included with an average age of 66 yr and average follow-up of 32 mo. Multivariable logistic regression analysis with an area under the curve (AUC) of 0.89 demonstrated HU at the UIV/UIV + 1 as the only independent predictor of PJK/PJF with an odds ratio of 0.94 (P-value = .031) for a change in a single HU. Patients with HU at UIV/UIV + 1 of <110 (n = 35), 110 to 160 (n = 73), and >160 (n = 42) had a rate of PJK/PJF of 63%, 27%, and 12%, respectively (P-value < .001). CONCLUSION Patients with lower HU at the UIV and UIV + 1 were significantly associated with PJK and PJF, with an optimal cutoff of 122 HU that maximizes sensitivity and specificity.
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Affiliation(s)
- Anthony L Mikula
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy L Fogelson
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Lakomkin
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick M Flanigan
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachariah W Pinter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Paul A Anderson
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Benjamin D Elder
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Echt M, Ranson W, Steinberger J, Yassari R, Cho SK. A Systematic Review of Treatment Strategies for the Prevention of Junctional Complications After Long-Segment Fusions in the Osteoporotic Spine. Global Spine J 2021; 11:792-801. [PMID: 32748633 PMCID: PMC8165922 DOI: 10.1177/2192568220939902] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-known complications after long-segment fusions in the thoracolumbar spine of osteoporotic patients. Recent advances in anti-resorptive and anabolic medications, instrumentation, surgical technique, and cement augmentation have all aided in the avoidance of junctional kyphosis. In this article, current literature on the prevention of PJK and PJF in the osteoporotic spine is reviewed. METHODS A systematic literature review was conducted using the PubMed/MEDLINE and Embase databases in order to search for the current preventive treatment methods for PJK and PJF published in the literature (1985 to present). Inclusion criteria included (1) published in English, (2) at least 1-year mean and median follow-up, (3) preoperative diagnosis of osteoporosis, (4) at least 3 levels instrumented, and (5) studies of medical treatment or surgical techniques for prevention of junctional kyphosis. RESULTS The review of the literature yielded 7 studies with low levels of evidence ranging from level II to IV. Treatment strategies reviewed addressed prophylaxis against ligamentous failure, adjacent vertebral compression fracture, and/or bone-implant interface failure. This includes studies on the effect of osteoporosis medication, cement augmentation, multi-rod constructs, and posterior-tension band supplementation. The role of perioperative teriparatide therapy maintains the highest level of evidence. CONCLUSIONS Perioperative teriparatide therapy represents the strongest evidence for preventive treatment, and further clinical trials are warranted. Use of cement augmentation, sublaminar tethers, and multi-rod constructs have low or insufficient evidence for recommendations. Future guidelines for adult spinal deformity correction may consider bone mineral density-adjusted alignment goals.
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Affiliation(s)
- Murray Echt
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William Ranson
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Reza Yassari
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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Xi Z, Duan PG, Mummaneni PV, Liu J, Guinn JMV, Wang M, Li B, Wu HH, Rivera J, Burch S, Berven SH, Chou D. Posterior Displacement of L1 May be a Risk Factor for Proximal Junctional Kyphosis After Adult Spinal Deformity Correction. Global Spine J 2021; 13:1042-1048. [PMID: 33998302 DOI: 10.1177/21925682211015651] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Overcorrection in adult spinal deformity (ASD) surgery may lead to proximal junctional kyphosis (PJK) because of posterior spinal displacement. The aim of this paper is to determine if the L1 position relative to the gravity line (GL) is associated with PJK. METHODS ASD patients fused from the lower thoracic spine to sacrum by 4 spine surgeons at our hospital were retrospectively studied. Lumbar-only and upper thoracic spine fusions were excluded. Spinopelvic parameters, the L1 plumb line (L1PL), L1 distance to the GL (L1-GL), and Roussouly type were measured. RESULTS One hundred fourteen patients met inclusion criteria (63 patients with PJK, 51 without). Mean age and follow up was 65.51 and 3.39 years, respectively. There was no difference between the PJK and the non-PJK groups in baseline demographics, pre-operative and immediate post-operative pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, or coronal Cobb. The immediate postoperative L1-GL was -7.24 cm in PJK and -3.45 cm in non-PJK (P < 0.001), L1PL was 1.71 cm in PJK and 3.07 cm in non-PJK (P = 0.004), and PT (23.76° vs 18.90°, P = 0.026) and TK (40.56° vs 31.39°, P < 0.001) were larger in PJK than in non-PJK. After univariate and multivariate analyses, immediate postoperative TK and immediate postoperative L1-GL were independent risk factors for PJK without collinearity. CONCLUSIONS A dorsally displaced L1 relative to the GL was associated with an increased risk of PJK after ASD surgery. The postoperative L1-GL distance may be a factor to consider during ASD surgery.
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Affiliation(s)
- Zhuo Xi
- Department of Neurosurgery, University of California San Francisco, USA.,Department of Neurosurgery, Shengjing Hospital of China Medical University, Liaoning, China
| | - Ping-Guo Duan
- Department of Neurosurgery, University of California San Francisco, USA
| | | | - Jinping Liu
- Department of Neurosurgery, University of California San Francisco, USA
| | - Jeremy M V Guinn
- Department of Neurosurgery, University of California San Francisco, USA
| | - Minghao Wang
- Department of Neurosurgery, University of California San Francisco, USA
| | - Bo Li
- Department of Neurosurgery, University of California San Francisco, USA
| | - Hao-Hua Wu
- Department of Orthopedic Surgery, University of California San Francisco, USA
| | - Joshua Rivera
- Department of Neurosurgery, University of California San Francisco, USA
| | - Shane Burch
- Department of Orthopedic Surgery, University of California San Francisco, USA
| | - Sigurd H Berven
- Department of Orthopedic Surgery, University of California San Francisco, USA
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, USA
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45
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Rabinovich EP, Snyder MH, McClure JJ, Buell TJ, Smith JS, Shaffrey CI, Buchholz AL. Posterior Polyethylene Tethers Reduce Occurrence of Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity: A Retrospective Analysis. Neurosurgery 2021; 89:227-235. [PMID: 33971008 DOI: 10.1093/neuros/nyab123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/30/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) is a common postoperative complication after adult spinal deformity (ASD) surgery and may manifest with neurological decline, worsening spinal deformity, and spinal instability, which warrant reoperation. Rates of PJK may be as high as 69.4% after ASD surgery. OBJECTIVE To evaluate the efficacy of junctional tethers for PJK prophylaxis after multilevel instrumented surgery for ASD with minimum 2-yr follow-up. METHODS Single-center retrospective analysis of adult patients (age ≥18 yr) who underwent ASD surgery with index operations performed between November 2010 and June 2016 and achieved minimum 2-yr follow-up. Patients with ASD were subdivided into 3 treatment cohorts based on institutional protocol: no tether (NT), polyethylene tether-only (TO), and tether with crosslink (TC). PJK was defined as a proximal junctional angle (PJA) >10° and 10° greater than the corresponding preoperative measurement. Patient demographics, operative details, standard radiographic scoliosis measurements (including PJA and assessment of PJK), and complications were analyzed. RESULTS Of 184 patients, 146 (79.3%) achieved minimum 2-yr follow-up (mean = 45 mo; mean age = 67 yr; 67.8% women). PJK rates reported for the NT, TO, and TC cohorts were 60.7% (37/61), 35.7% (15/42), and 23.3% (10/43), respectively. PJK rates among TC patients were significantly lower than NT (P = .01601). CONCLUSION Junctional tethers with crosslink significantly reduced the incidence of PJK and revisions for PJK among ASD patients treated with long-segment posterior instrumented fusions who achieved minimum 2-yr follow-up.
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Affiliation(s)
- Emily P Rabinovich
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - M Harrison Snyder
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jesse J McClure
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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46
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Kim HJ, Yang JH, Chang DG, Suk SI, Suh SW, Kim SI, Song KS, Park JB, Cho W. Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies. Asian Spine J 2021; 16:440-450. [PMID: 33910320 PMCID: PMC9260397 DOI: 10.31616/asj.2020.0574] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/15/2021] [Indexed: 12/03/2022] Open
Abstract
Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.
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Affiliation(s)
- Hong Jin Kim
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Se-Il Suk
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang-Sup Song
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woojin Cho
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Kim WJ, Shin HM, Song DG, Lee JW, Park KY, Chang SH, Bae JH, Choy WS. Comparison of Clinical Outcomes and Complications of Primary and Revision Surgery Using a Combined Anterior and Posterior Approach in Patients with Adult Spinal Deformity and Sagittal Imbalance. Clin Orthop Surg 2021; 13:196-206. [PMID: 34094010 PMCID: PMC8173245 DOI: 10.4055/cios20217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/12/2020] [Accepted: 11/05/2020] [Indexed: 11/13/2022] Open
Abstract
Backgroud The purpose of this study was to compare clinical outcomes and complications of primary and revision surgery in patients with adult spinal deformity (ASD) accompanied by sagittal imbalance. Revision surgery has been associated with poor clinical outcomes and increased risk of complications. Previous studies comparing primary versus revision surgery included data for a wide variety of diseases and ages, but few investigated patients with ASD with sagittal imbalance undergoing anterior and posterior combined surgery. Methods Retrospective cohort analysis of prospectively collected data. We identified 60 consecutive patients with ASD combined with sagittal imbalance who underwent primary or revision surgery; of these, 6 patients were excluded for lack of a minimal 2-year follow-up. Patients' surgical and radiological data, clinical outcomes, and complications were reviewed. Results There were 30 patients in the primary group and 24 patients in the revision group. Patient characteristics, including the prevalence of sarcopenia, were similar between the two groups. Pedicle subtraction osteotomy was performed more frequently in the revision group although there was no statistically significant difference between groups. The primary group had more proximal junctional problems, whereas the revision group had more rod breakage (p < 0.05). There were significant improvements in clinical outcomes in both groups when the preoperative and 2-year postoperative values were compared. The Oswestry disability index and visual analog scale score were similar in both groups 2 years postoperatively. Conclusions Considering the greater pain and disability at the time of the revision procedure, revision patients benefited more from surgery at the 2-year follow-up than the primary surgery patients. Complication rates were similar between the groups except for proximal junctional problems and rod breakage. Therefore, revision surgery should not be avoided in the treatment of ASD patients with sagittal imbalance.
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Affiliation(s)
- Whoan Jeang Kim
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Hyun Min Shin
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Dae Geon Song
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Jae Won Lee
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Kun Young Park
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Shann Haw Chang
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Jin Hyun Bae
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Won Sik Choy
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
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Who Will Require Revision Surgery Among Neurologically Intact Patients with Proximal Junctional Failure After Surgical Correction of Adult Spinal Deformity? Spine (Phila Pa 1976) 2021; 46:520-529. [PMID: 33290367 DOI: 10.1097/brs.0000000000003850] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To identify the risk factors for revision surgery among neurologically intact patients with proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA PJF following long fusion for ASD is a well-recognized complication that negatively affects clinical outcomes. However, revision surgery is not required for every patient with PJF especially if the patient does not present with neurologic deficit. Identifying the risk factors of revision surgery is necessary to determine who will need revision surgery as well as when is the right time for the revision surgery. METHODS Sixty-nine neurologically intact patients with PJF following ASD surgery were followed up with more than 2 years after PJF development or until undergoing revision surgery. PJF was divided into ligamentous failure (proximal junctional angle [PJA] of more than 20°) and bony failure. According to the conduct of revision surgery, two groups (revision and no revision) were created. Risk factors for revision surgery were analyzed in univariate and multivariate analysis with regard to patient, surgical and radiographic variables. RESULTS The mean age at the time of PJF development was 70.9 years. There were 45 patients with bony failure and 24 with ligamentous failure. Revision surgery was performed for 23 patients (33.3%). Multivariate analysis revealed that bony failure (odds ratio: 10.465) and PJA (odds ratio: 1.131) were significant risk factors. For those with bony failure, the cutoff value of PJA for performing revision surgery was calculated as 22°. The revision rate was significantly highest in patients (63.6%) with bony failure + PJA 22° or higher followed by patients (26.1%) with bony failure + PJA less than 22° and patients (12.5%) with ligamentous failure (P = 0.002). CONCLUSION Bony failure with PJA of greater than 22° increased the likelihood for revision surgery. Therefore, early surgical intervention should be considered in these patients.Level of Evidence: 4.
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49
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Ozak A, Altas M. Revision surgery of postoperative kyphotic deformity: A case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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50
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Garcia EB, Garcia LF, Garcia Júnior EB, Sá AD, Matos VDO, Camarinha JG, Camarinha MF, Gonçalves RG, Garcia EB, Giesbrecht ST. COMPARATIVE STUDY OF THE TYPES OF FIXATION IN ADOLESCENT IDIOPATHIC SCOLIOSIS. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212001232530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: To conduct a comparative study of the results obtained in the treatment of adolescent idiopathic scoliosis (AIS) with different types of fixations (traditional, selective and multiple), and to evaluate the correction of angular deformity in the frontal plane by the Cobb and sacral clavicular angle (SCA) methods. Methods: A study of a group of 278 patients with AIS who underwent selective, traditional, and multiple fixation surgeries. Results: Significant corrections of both the Cobb angle and the SCA were observed. Conclusions: In the multiple fixation surgeries there was a 100% correction between the preoperative and postoperative SCA values and a 50% correction in the traditional and selective fixations, a difference considered significant. Regarding the Cobb angle, the three fixations presented corrections between preop and postop with significant differences. Level of evidence III; Retrospective Study.
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Affiliation(s)
- Enguer Beraldo Garcia
- Santa Casa de Belo Horizonte, Brazil; Instituto da Coluna Vertebral de Belo Horizonte, Brazil; Sociedade Brasileira de Coluna, Brazil; Universidade Federal de Minas Gerais, Brazil
| | - Liliane Faria Garcia
- Santa Casa de Belo Horizonte, Brazil; Instituto da Coluna Vertebral de Belo Horizonte, Brazil
| | | | | | | | | | | | | | - Eduardo Beraldo Garcia
- Santa Casa de Belo Horizonte, Brazil; Instituto da Coluna Vertebral de Belo Horizonte, Brazil
| | - Saulo Terror Giesbrecht
- Santa Casa de Belo Horizonte, Brazil; Instituto da Coluna Vertebral de Belo Horizonte, Brazil
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