Identification of Decision Criteria for Revision Surgery Among Patients With Proximal Junctional Failure After Surgical Treatment of Spinal Deformity

Dallas, TX Southern Methodist University
Spine (Impact Factor: 2.45). 06/2013; 38(19). DOI: 10.1097/BRS.0b013e31829fedde
Source: PubMed

ABSTRACT Study Design: Multi-center, retrospective, consecutive case series.Objective: This study aims to identify demographic and radiographic characteristics that influence the decision to perform revision surgery among patients with Proximal Junctional Failure (PJF).Summary of Background Data: Revision rates following PJF remain relatively high, yet the decision criteria for performing revision surgeries is not uniform and varies by surgeon. A better understanding of the factors that impact the decision to perform revision surgery is important in order to improve efficiency of surgical treatment for adult spinal deformity (ASD).Methods: A cohort of 57 PJF patients was identified retrospectively from 1,218 consecutive ASD patients. PJF was identified based on 10° post-operative increase in kyphosis between upper instrumented vertebra (UIV) and UIV+2, along with one or more of the following: fracture of the vertebral body of UIV or UIV +1, posterior osseo-ligamentous disruption, or pull-out of instrumentation at the UIV. Univariate statistical analysis was performed using t-tests and Fisher's exact tests. Multivariate analysis was performed using logistic regression.Results: Twenty-seven (47.4%) patients underwent revision surgery within 6 months of the index operation. Regression results revealed that patients with combined posterior/anterior approaches at index were significantly more likely to undergo revision (p = 0.001) as were patients with more extreme PJK angulation (p = 0.034). Patients sustaining trauma were also significantly more likely to undergo revision (p = 0.019). Variables approaching but not reaching significance as predictors of revision included female gender (p = 0.066) and higher SVA (p = 0.090).Conclusions: The decision to perform revision surgery is complicated and varies by surgeon. Factors that appear to influence this decision include traumatic etiology of PJF, severity of PJK angulation, higher SVA, and female gender. Factors that were expected to influence revision but had no statistical effect included soft-tissue versus bony mode of failure, age, levels fused, and upper thoracic versus thoracolumbar proximal junction.

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    ABSTRACT: Proximal junctional kyphosis (PJK) is a common radiographic finding following long spinal fusions. Whether PJK leads to negative clinical outcome is currently debatable. A systematic review was performed to assess the prevalence, risk factors, and treatments of PJK. Literature search was conducted on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials using the terms 'proximal junctional kyphosis' and 'proximal junctional failure'. Excluding reviews, commentaries, and case reports, we analyzed 33 studies that reported the prevalence rate, risk factors, and discussions on PJK following spinal deformity surgery. The prevalence rates varied widely from 6 to 61.7 %. Numerous studies reported that clinical outcomes for patients with PJK were not significantly different from those without, except in one recent study in which adult patients with PJK experienced more pain. Risk factors for PJK included age at operation, low bone mineral density, shorter fusion constructs, upper instrumented vertebrae below L2, and inadequate restoration of global sagittal balance. Prevalence of PJK following long spinal fusion for adult spinal deformity was high but not clinically significant. Careful and detailed preoperative planning and surgical execution may reduce PJK in adult spinal deformity patients.
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    ABSTRACT: Purpose To analyze risk factors for an increase in proximal junctional angle (PJA) after posterior selective thoracolumbar/lumbar (TL/L) curve fusion in patients with adolescent idiopathic scoliosis (AIS). Methods AIS patients that underwent selective posterior TL/L curve fusion with a minimum of 2-year follow-up were identified. Demographic and radiographic data were collected before surgery, at first erect after surgery and at final follow-up. Multiple linear regression analysis was performed to determine the relation of PJA changes during follow-up and eight potential risk factors, including locations of upper instrumented vertebra (UIV), locations of lower instrumented vertebra (LIV), length of fusion segments, types of pedicle screw alignment, lumbar lordosis (LL) at first erect after surgery, LL changes before and after surgery, sagittal vertical axis (SVA) at first erect after surgery and SVA changes before and after surgery. Results A total of 41 patients were included in this study. There were 37 female and 4 male with a mean age of 14.7 years at surgery. PJA was increased from 5.5° immediately after surgery to 10.8° at the last follow-up (P Conclusions Location of LIV above or equal to L3, higher postoperative LL and deteriorative negative SVA with surgery were potential risk factors for increased PJA during follow-up. Postoperative LIV inclination more than 5ºmight be also an indicator for an increase in PJA.
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