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: 2.3).
06/2013; 38(19). DOI: 10.1097/BRS.0b013e31829fedde
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.
Available from: Bassel G. Diebo
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ABSTRACT: The surgical treatment of adult spinal deformity has been shown to offer superior clinical and radiographic outcomes compared with nonoperative approaches; furthermore, osteotomies are increasingly applied for treating spinal deformities. Establishing a plan for a patient suffering from marked spinal deformity is a matter of consideration of certain radiographic parameters which correlate with health-related quality of life scores, adherence to consistent principles of alignment and established formulas, and selecting the appropriate osteotomies. This is a review of the most recent work on vertebral osteotomies and includes a summary of a systematic and anatomically based osteotomy classification. A universal classification will facilitate communication, standardize outcomes research, and establish a framework upon which indications can be properly studied and described. Ongoing multicenter collaboration is certain to drive a more evidence-based approach to the complex clinical scenarios of patients suffering from spinal deformity.
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To evaluate the clinical outcome of surgical management for post-traumatic thoracolumbar kyphotic deformity with single-stage posterior transpedicularlimited osteotomies.
From March 2007 to May 2010, 17 patients with post-traumatic thoracolumbar kyphotic deformity treated with posterior limited transpedicular osteotomy were admitted. The preoperative Cobb angle was 41°-62°(52.5° ±6.4°). Sagittal balance was evaluated by the standing lateral films measuring the C7 plumb line distance (C7 PLD) from the posterior superior corner of S1. The C7 PLD was 18-58 (41.2 ±12.4) mm in the sagittal plane. The preoperative oswestry disability index (ODI) was 42-50 (45.7 ±2.7), and the average preoperative visual analogue scale (VAS) was 8-10 (8.8 ±0.7). The American Spinal Injury Association (ASIA) impairment scale was used to assess the neurological deficits, and grade C in 1 patient, grade D in 7 and grade E in 9 patients. The operation time, blood loss, complications, post-operative Cobb angle, ODI and VAS score at the follow-up were collected and analyzed.
The average duration of postoperative follow-up was 24-53 (34.5 ±7.1) months. The operation time was 180-400 (287.1 ±65.9) min, with an blood loss of 350-1 300 (838.2 ±276.4) mL. The postoperative kyphotic angle was 3°-12° (6.1° ±3.0°), and it was 7.5° ±2.6° at the final follow-up evaluation. The postoperative C7PLD was (3.6 ±3.9) mm and it was (3.4 ±2.3) mm at the final follow-up evaluation. Postoperatively, the ASIA impairment scale was grade D in 4 and grade E in 13 patients. At the final follow-up ODI and VAS were reduced to an average of 5.2 ±2.4 and 2.4 ±1.0, respectively. Cerebrospinal fluid leakage was found in 2 patients, deep wound infection in 1, and intercostal neuralgia in 2. All the complications were relieved after conservative medical therapy. One patient received additional surgery at postoperative 12 weeks due to breakage of posterior implants. Another screw pullout case was treated with reinsertion of larger screws at postoperative 4 months. Solid fusion was confirmed by plain film and CT scan in all patients within 1 year after the surgery.
Single-staged posterior transpedicular limited osteotomies is safe and effective to correct post-traumatic thoracolumbar kyphotic deformity.
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ABSTRACT: Study Design: Retrospective review. Objective: To study time to development, clinical and radiographic characteristics, and management of proximal junctional kyphosis (PJK) following thoracolumbar instrumented fusion for adult spinal deformity (ASD). Summary of Background Data: PJK continues to be a common mode of failure following ASD surgery. Although literature exists on possible risk factors, data on management remains limited. Methods: A retrospective review of medical records of 289 consecutive ASD patients who underwent posterior segmental instrumentation incorporating at least five segments was conducted. PJK was defined as proximal kyphotic angle >10[degrees]. Results: PJK occurred in 32 patients (11%) at a mean follow-up of 34 months (1.3-61.9+/-19 mo). 16 (50%) patients were revised (mean 1.7 revisions, range: 1-3) at a mean follow up of 9.6 months (range: 0.7-40 mo); primary indications for revision were pain (n=16), myelopathy (n=6), instability (n=4), and instrumentation protrusion (n=2). Comparison of pre- and post-index surgery radiographic parameters demonstrated significant improvement in mean lumbar lordosis (LL) (24[degrees] vs. 42[degrees], P<0.001), pelvic incidence (PI)-LL mismatch (30[degrees] vs. 11[degrees], P<0.001), and pelvic tilt (PT) (29[degrees] vs. 23[degrees], P<0.011). The mean T5-T12 kyphosis worsened (30[degrees] vs. 53[degrees], P<0.001) and the mean global sagittal spinal alignment failed to improve (9.6 cm vs. 8.0 cm, P=0.76). There was no apparent relationship between the absolute PJK angle and revision surgery (P>0.05). Conclusions: The patients in this series who developed PJK had substantial pre-operative positive sagittal malalignment that remained inadequately corrected following surgery, likely resulting from a combination of inadequate surgical correction and a significant compensatory increase in thoracic kyphosis. In the absence of direct relationship between a greater PJK angle and worse clinical outcome, clinical symptoms and neurological status rather than absolute reliance on radiographic parameters should drive the decision to pursue revision surgery.
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