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Han MS, Hong JH, Jung JH, Lee JK. Normal Functional Local Alignment and Segmental Motion at the Thoracolumbar Junction: A Cross-Sectional Study of Healthy Subjects. World Neurosurg 2024; 186:e713-e720. [PMID: 38616027 DOI: 10.1016/j.wneu.2024.04.038] [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: 02/14/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Several studies have investigated the mechanical behavior of the thoracolumbar spine. However, finding an accurate reference for the normal functional local alignment and segmental motion (SM) at the thoracolumbar junction (TLJ) is challenging. Therefore, this study aimed to assess age- and sex-related changes and differences in local alignment and SM at the TLJ. METHODS The study recruited healthy subjects aged 20 to 79 without complaints of back pain. Healthy subjects (60 males and 60 females) with appropriate imaging results were enrolled in the study. The subjects were divided into age groups (20-29, 30-39, 40-49, 50-59, 60-69, and 70-79 years); each group included 10 subjects of each sex. RESULTS The SM at the TLJ was small but noticeable, and the motion gradually increased toward the lower level of the TLJ, closer to the lumbar region. No significant differences were observed between male and female subjects in any SM measurements at the TLJ. The SM at the TLJ gradually decreased with age, while local kyphosis of TLJ progressed. The results also showed that the thoracolumbar slope value did not change with age and remained at a mean of -12.8 ± 7.2° (P = 0.893). CONCLUSIONS This study's results provide valuable guidance for appropriate surgical planning and rehabilitation of patients with spinal diseases or trauma. Furthermore, the results can be the basis for categorizing accurate criteria to evaluate the degree of disability after treatment.
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Affiliation(s)
- Moon-Soo Han
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jong-Hwan Hong
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Ji-Ho Jung
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea.
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Haldeman PB, Ward SR, Osorio J, Shahidi B. An evidence based conceptual framework for the multifactorial understanding of proximal junctional kyphosis. BRAIN & SPINE 2024; 4:102807. [PMID: 38712018 PMCID: PMC11070827 DOI: 10.1016/j.bas.2024.102807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/22/2024] [Accepted: 04/04/2024] [Indexed: 05/08/2024]
Abstract
Introduction Adult spinal deformity (ASD) is a debilitating pathology that arises from a variety of etiologies. Spinal fusion surgery is the mainstay of treatment for those who do not achieve symptom relief with conservative interventions. Fusion surgery can be complicated by a secondary deformity termed proximal junctional kyphosis (PJK). Research question This scoping review evaluates the modern body of literature analyzing risk factors for PJK development and organizes these factors according to a multifactorial framework based on mechanical, tissue or demographic components. Materials and methods An extensive search of the literature was performed in PubMed and Embase back to the year 2010. Articles were assessed for quality. All risk factors that were evaluated and those that significantly predicted the development of PJK were compiled. The frequency that a risk factor was predictive compared to the number of times it was evaluated was calculated. Results 150 articles were reviewed. 57.3% of papers were of low quality. 76% of risk factors analyzed were focusing on the mechanical contribution to development of PJK versus only 5% were focusing on the tissue-based contribution. Risk factors that were most frequently predictive compared to how often they were analyzed were Hounsfield Units of vertebrae, UIV disc degeneration, paraspinal muscle cross sectional area and fatty infiltration, ligament augmentation, instrument characteristics, postoperative hip and lower extremity radiographic metrics, and postoperative teriparatide supplementation. Discussion and conclusion This review finds a multifactorial framework accounting for mechanical, patient and tissue-based risk factors will improve the understanding of PJK development.
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Affiliation(s)
| | - Samuel R. Ward
- Department of Orthopaedic Surgery, UC San Diego, La Jolla, CA, USA
| | - Joseph Osorio
- Department of Neurological Surgery, UC San Diego, La Jolla, CA, USA
| | - Bahar Shahidi
- Department of Orthopaedic Surgery, UC San Diego, La Jolla, CA, USA
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Lovecchio F, Lafage R, Sheikh Alshabab B, Shah S, Punyala A, Ang B, Akosman I, Charles Elysee J, Lafage V, Schwab F, Kim HJ. Can Discharge Radiographs Predict Junctional Complications? A Decision Tree Analysis. Global Spine J 2024; 14:970-977. [PMID: 36194520 PMCID: PMC11192123 DOI: 10.1177/21925682221131765] [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: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To determine if standing pre-discharge radiographs can predict the development of junctional complications. MATERIALS AND METHODS Adult spinal deformity patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) were included. All patients underwent full-length standing radiographs before hospital discharge. Outcomes of interest included 2-year radiographic PJK and proximal junctional failure (PJF). Patients were stratified into 3 exclusive groups: No PJK, PJK, and PJF. Chi-square automatic interaction detection (CHAID) decision tree analysis was utilized to identify pre-discharge proximal junctional angle (PJA) thresholds associated with increased risk of PJK or PJF. RESULTS The 117 study patients had a mean age 65.8 ± 8.5, BMI 27.2 ± 4.9, PI-LL 23.3 ± 17.4, TPA 27.2 ± 11.5. Sample was stratified into 64 (54.7%) No PJK, 39 (33.3%) PJK, 14 (12.0%) PJF. No differences were detected between cohorts in discharge alignment, preop-discharge change, or offset from age-adjusted alignment targets (P > .005). Decision tree analysis showed that the first branch point depended on the UIV, as most patients with an UT UIV did not develop PJK or PJF (no PJK, 67.4%). For patients with an LT UIV, a second branch point occurred based on the ΔPJA. 89.5% of LT patients with a ΔPJA < 4.3° were free of radiographic PJK and PJF. The third branch point occurred based on the PJA at discharge. Thus, the highest risk group was comprised of ΔPJA ≥4.3° and PJA > 15.5°, as 57.1% of developed PJF and 28.6% PJK. CONCLUSION Most patients with a lower thoracic UIV, preop-discharge ΔPJA ≥4.3°, and discharge PJA > 15.5° develop PJF.
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Affiliation(s)
- Francis Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Sachin Shah
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Ananth Punyala
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Bryan Ang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Park SJ, Kim HJ, Lee CS, Park JS, Jung CW, Lee JS, Yang HS. Clinical Significance of Lordosis Orientation on Proximal Junctional Kyphosis Development in Long-Segment Fusion Surgery for Adult Spinal Deformity. World Neurosurg 2024; 183:e282-e292. [PMID: 38135150 DOI: 10.1016/j.wneu.2023.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE We sought to evaluate the clinical impact of lordosis orientation (LO) on proximal junctional kyphosis (PJK) development in adult spinal deformity surgery. METHODS This study included 152 patients who underwent low thoracic (T9-T12) to pelvis fusion and were followed up for ≥2 years. In the literature, 6 radiographic parameters representing LO were introduced, such as uppermost instrumented vertebra (UIV) slope, UIV inclination, UIV-femoral angle (UIVFA), thoracolumbar tilt, thoracolumbar slope, and lordosis tilt. Various clinical and radiographic factors including 6 LO parameters were investigated using logistic regression analysis to identify risk factors for PJK. RESULTS The mean age was 69.4 years, and 136 patients were females (89.5%). PJK developed in 65 patients (42.8%). Multivariate logistic regression analysis revealed that only small postoperative pelvic incidence (PI)-lumbar lordosis (LL) (odds ratio [OR] = 0.962, 95% confidence interval: 0.929-0.996, P = 0.030) and large UIVFA (OR = 1.089, 95% confidence interval: 1.028-1.154, P = 0.004) were significant for PJK development. UIVFA showed significantly positive correlation with pelvic tilt (CC = 0.509), thoracic kyphosis (CC = 0.384), and lordosis distribution index (CC = 0.223). UIVFA was also negatively correlated with sagittal vertical axis (CC = -0.371). However, UIVFA did not correlate with LL, PI-LL, or T1 pelvic angle. CONCLUSIONS LO significantly increases the risk of PJK development in ASD surgery. Multivariate analysis revealed that smaller postoperative PI-LL and greater UIVFA were significant risk factors for PJK. Surgeons should avoid undercorrection and overcorrection to prevent PJK development.
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Affiliation(s)
- Se-Jun Park
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun-Jun Kim
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Chong-Suh Lee
- Departments of Orthopedic Surgery, Haeundae Bumin Hospital, Busan, South Korea
| | - Jin-Sung Park
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Choong-Won Jung
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong-Shin Lee
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Han-Seok Yang
- Departments of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Lovecchio F, Lafage R, Kim HJ, Bess S, Ames C, Gupta M, Passias P, Klineberg E, Mundis G, Burton D, Smith JS, Shaffrey C, Schwab F, Lafage V. Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why? Spine (Phila Pa 1976) 2024; 49:157-164. [PMID: 37847773 DOI: 10.1097/brs.0000000000004852] [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: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 10/19/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
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Affiliation(s)
- Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center/Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, IL
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, The University of Texas Health Science Center of Houston, Houston, TX
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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Park SJ, Lee CS, Park JS, Shin TS. Introduction of a New Radiographic Parameter to Predict Proximal Junctional Kyphosis in Adult Spinal Deformity: UIVPTA (Uppermost Instrumented Vertebra-Pelvic Tilt Angle). Neurospine 2023; 20:969-980. [PMID: 37798991 PMCID: PMC10562231 DOI: 10.14245/ns.2346420.210] [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: 04/08/2023] [Revised: 05/23/2023] [Accepted: 06/26/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE To introduce a new sagittal parameter, uppermost instrumented vertebra-pelvic tilt angle (UIVPTA), and to determine the effects on the proximal junctional kyphosis (PJK) development in adult spinal deformity (ASD) surgery. METHODS Patients ≥ 60 years with ASD who underwent low thoracic spine to pelvis fusion with a minimum of 2-years of follow-up were included in this study. Two groups were created according to PJK development. Various clinical and radiographic factors were compared between PJK and non-PJK groups to identify the risk factors for PJK. Cutoff value of UIVPTA for PJK development was calculated using receiver operating characteristic curve according to different pelvic incidence groups. Linear regression analysis was performed to identify factors to affect UIVPTA. RESULTS One hundred fifity-one patients were included in this study. There were 135 female patients (89.4%). Mean age was 70.5 years. PJK developed in 65 patients (43.0%). Multivariate analysis showed that overcorrection relative to age-adjusted pelvic incidence (PI) minus lumbar lordosis (LL) (PI-LL) target and lower UIVPTA were independent risk factors for PJK. The cutoff value of UIVPTA for PJK development was calculated as 4.0° in patients with PI less than 45°, 9.5° in patients with PI between 45° and 60°, and 13.0° in patients with PI greater than 60°. Linear regression analysis showed that UIVPTA was positively affected by postoperative values of LL (coefficient = 0.505), PI-LL (coefficient = 0.674), and pelvic tilt (coefficient = 0.286). CONCLUSION Optimal correction within the age-adjusted PI-LL combined with keeping UIVPTA within optimal range is suggested for the prevention of PJK.
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Affiliation(s)
- Se-Jun Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Haeundae Bumin Hospital, Busan, Korea
| | - Jin-Sung Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Soo Shin
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Raganato R, Pizones J, Yilgor C, Moreno-Manzanaro L, Vila-Casademunt A, Sánchez-Márquez JM, Fernández-Baíllo N, Sánchez Pérez-Grueso FJ, Kleinstück F, Alanay A, Obeid I, Pellisé F. Sagittal realignment: surgical restoration of the global alignment and proportion score parameters: a subgroup analysis. What are the consequences of failing to realign? 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; 32:2238-2247. [PMID: 37000217 DOI: 10.1007/s00586-023-07649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION The Global Alignment and Proportion (GAP) score incorporates three domains directly modified with surgery (relative pelvic version-RPV, relative lumbar lordosis-RLL, lumbar distribution index-LDI) and one indirectly restored (relative spinopelvic alignment-RSA). We analyzed our surgical realignment performance and the consequences of domain-specific realignment failure on mechanical complications and PROMs. MATERIALS AND METHODS From an adult spinal deformity prospective multicenter database, we selected patients: fused to pelvis, upper instrumented vertebra at or above L1, and 2 years of follow-up. Descriptive, univariate and multivariate analyses were employed. RESULTS The sample included 333 patients. RLL-6w showed the highest success rate (58.3% aligned), but 16.5% of patients were classified in the "Severe hypolordosis" and "Hyperlordosis" subgroups. RPV-6w was the most challenging to realign, with 51.6% moderate or severe retroversion. Regarding RSA-6w, 21.9% had severe positive malalignment. Correct alignment of RPV-6w (p = 0.025) and RSA-6w (p = 0.002) proved to be protective factors against the development of mechanical complications. Severe pelvic retroversion (p = 0.026) and severe positive malalignment (p = 0.007) were risk factors for mechanical complications. RSA-6w "Severe positive malalignment" was associated with less improvement in PROMs: ∆ODI (8.83 vs 17.2; p = 0.011), ∆SRS-22 total (0.54 vs 0.87; p = 0.007), and ∆SF-36PCS (3.47 vs 7.76; p = 0.04); MCID for ODI (37.0 vs 55.5%; p = 0.023), and SRS-22 (40.8 vs 60.1%; p = 0.015); and PASS for ODI (17.6 vs 31.7%; p = 0.047). CONCLUSIONS RPV was the most underperformed modifiable parameter. Severe pelvic retroversion and severe positive malalignment influenced the occurrence of mechanical complications. Severe positive malalignment affected PROMs improvement.
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Affiliation(s)
- Riccardo Raganato
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | - Javier Pizones
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain.
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Lucía Moreno-Manzanaro
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | | | - José Miguel Sánchez-Márquez
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | - Nicomedes Fernández-Baíllo
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | | | - Frank Kleinstück
- Department of Orthopedics, Schulthess Klinik, Zurich, Switzerland
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ibrahim Obeid
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Ham DW, Kim HJ, Park SM, Park SJ, Park J, Yeom JS. The importance of thoracolumbar junctional orientation, change in thoracolumbar angle, and overcorrection of lumbar lordosis in development of proximal junctional kyphosis in adult spinal deformity surgery. J Neurosurg Spine 2022; 37:874-882. [PMID: 35901696 DOI: 10.3171/2022.5.spine211528] [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: 12/09/2021] [Accepted: 05/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Changes in the thoracolumbar angle (TLA) would play a pivotal role in the reciprocal changes following spine realignment surgery, thereby leading to the development of proximal junctional kyphosis (PJK). This study aimed to investigate the association between TLA and the development of PJK following adult spinal deformity surgery. METHODS A total of 107 patients were divided into PJK+ and PJK- groups according to the development of PJK within 12 months after surgery. The TLA and spinopelvic radiological parameters were compared between the PJK+ and PJK- groups. A multivariate logistic regression model was used to identify the risk factors for PJK. The receiver operating characteristic curves of the regression models were used to investigate the cutoff values of significant parameters needed so that PJK would not occur. RESULTS The change in TLA (ΔTLA) in the PJK+ group was significantly larger than in the PJK- group (6.7° ± 7.9° and 2.2° ± 8.1°, respectively; p = 0.006). Multivariate logistic regression analysis demonstrated that age, postoperative pelvic incidence-lumbar lordosis, and ΔTLA were significant risk factors for PJK. The risk of developing PJK was higher when the postoperative pelvic incidence-lumbar lordosis was < 5.2 and the ΔTLA was > 3.58°. CONCLUSIONS The present study highlights the thinking that extensive correction of TLA and lumbar lordosis should be avoided in patients with adult spinal deformity. Overcorrection of TLA of > 3.58° could result in higher odds of PJK.
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Affiliation(s)
- Dae-Woong Ham
- 1Department of Orthopedic Surgery, Chungang University Hospital, Seoul
| | - Ho-Joong Kim
- 2Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam; and
| | - Sang-Min Park
- 2Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam; and
| | - Se Jin Park
- 2Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam; and
| | - Jiwon Park
- 3Department of Orthopedic Surgery, Korea University Ansan Hospital, Gyeonggi-do, South Korea
| | - Jin S Yeom
- 2Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam; and
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9
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Ham CH, Park YK, Kim JH, Kwon WK, Kim DW, Moon HJ. Characteristics of Sagittal Spinopelvic Alignment Changes After Symptom Relief After Simple Lumbar Decompression. Neurosurgery 2022; 91:331-338. [PMID: 35506942 DOI: 10.1227/neu.0000000000002013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sagittal spinopelvic alignment (SSPA) parameters are essential for the diagnosis of adult spinal deformities (ASDs) and their progression. Certain clinical symptoms that occur in patients with lumbar spinal stenosis (LSS) and herniated nucleus pulposus (HNP) may distort the SSPA and mimic ASD. OBJECTIVE To differentiate SSPA in symptomatic patients from asymptomatic patients within 10 minutes in the standing position. METHODS This retrospective cohort study evaluated changes in SSPA after simple lumbar decompression surgery in patients with LSS and HNP. Relative sagittal alignment (RSA), relative pelvic version, relative lumbar lordosis (RLL), Lordosis Distribution Index (LDI), and global alignment and proportion (GAP) values were calculated using the conventional Schwab classification method. First, the preoperative and postoperative SSPA parameters were compared. Second, patients were subgrouped into symptomatic within 10 minutes of standing (SP group) and other symptoms of LSS and HNP as controls. Changes in SSPA parameters after symptom relief after simple lumbar decompression surgery were compared between the two groups. RESULTS Overall, all SSPA parameters improved after surgery. However, after subgrouping, patients in the control group did not show significant SSPA alterations, except for LDI, whereas patients in the SP group significantly improved in terms of their RSA, RLL, LDI, and GAP values after symptom relief after surgery. CONCLUSION Patients with pain on standing within 10 minutes showed significant correction in RSA, RLL, and GAP values after simple lumbar decompression. Therefore, it is important to observe such clinical symptoms to avoid misdiagnosis of ASD.
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Affiliation(s)
- Chang Hwa Ham
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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10
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Pizones J, Perez-Grueso FJS, Moreno-Manzanaro L, Escámez F, Yilgor C, Vila-Casademunt A, Fernández-Baíllo N, Sánchez-Márquez JM, Obeid I, Kleinstück F, Alanay A, Pellisé F. Compensatory mechanisms recruited against proximal junctional kyphosis by patients instrumented from the thoracolumbar junction to the iliac. 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 2021; 31:112-122. [PMID: 34750669 DOI: 10.1007/s00586-021-07042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 10/12/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The compensatory mechanisms recruited by un-instrumented patients against sagittal imbalance are well documented. However, there is a lack of information regarding instrumented patients. MATERIAL AND METHODS We performed a retrospective analysis of data collected prospectively in a multicenter adult spinal deformity database. We included patients suffering PJK/PJF after (T8-L2) to iliac instrumentation with minimum two-year follow-up. We measured quantitative sagittal spinopelvic and qualitative sagittal distribution parameters in the immediate postoperative period (6w) and at the time of PJK/PJF appearance. We analyzed how these parameters changed comparing these two time points with univariate and multivariate logistic regression analyses. RESULTS A total of 69 patients were included. Two different patterns at PJK/PJF were found: 36 patients activated compensation (defined as an increase in pelvic retroversion (ΔRPV > 5º), and 33 did not (ΔRPV < 5º). The difference in behavior relied mostly on the amount of not surgically restored pelvic rotation at 6w (OR: 0.6; CI95%: 0.4-9.2; P = 0.017). Non-compensators had less rotation reserve (PTx100/PI = 33.9% vs 47.8%;P < 0.001) associated with worse 6w relative pelvic version and lower lumbar arc restoration, worse 6w relative sagittal alignment and GAP-score, compared with compensators (P < 0.001). Compensators' response was based on pelvic retroversion, causing lower lumbar arc decrease, lumbar apex caudal migration, and upper lumbar arc posterior inclination. Despite compensation, a thoracic kyphosis increase in both upper and lower arches gradually evolved into a PJK/PJF. Non-compensators did not react to PJK/PJF, which forced them into kyphosis from the lumbar apex and extending cranially, mainly throughout the upper thoracic arc. CONCLUSIONS In patients fused from the TL junction to the iliac, those having greater postoperative pelvic rotation reserve showed greater capacity to recruit compensatory mechanisms against PJK/PJF.
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Affiliation(s)
- Javier Pizones
- Department of Orthopedic Surgery, Spine Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
| | | | - Lucía Moreno-Manzanaro
- Department of Orthopedic Surgery, Spine Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Fernando Escámez
- Department of Orthopedic Surgery, Spine Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | | | - Nicomedes Fernández-Baíllo
- Department of Orthopedic Surgery, Spine Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - José Miguel Sánchez-Márquez
- Department of Orthopedic Surgery, Spine Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Ibrahim Obeid
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
| | - Frank Kleinstück
- Department of Orthopedics, Schulthess Klinik, Zurich, Switzerland
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Moon BJ, Han MS, Kim JY, Lee JK. Thoracolumbar Slope Is Useful Parameter for Evaluating HealthRelated Quality of Life and Sagittal Imbalance Aggravation in Adult Spinal Deformity: A Prospective Observational Cohort Study. Neurospine 2021; 18:467-474. [PMID: 34610676 PMCID: PMC8497235 DOI: 10.14245/ns.2142408.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/07/2021] [Indexed: 01/18/2023] Open
Abstract
Objective The purpose of the present study was to evaluate the natural course of primary degenerative sagittal imbalance (PDSI), its aggravating factors, and health-related quality of life (HRQoL) associated with various spinal alignment parameters (SAPs) in patients with PDSI who have not undergone surgery.
Methods One hundred three participants volunteered to participate. The SAPs, including T1 pelvic angle (T1PA), thoracolumbar tilt, and thoracolumbar slope (TLS), were measured on whole-spine standing radiographs. The back and lumbar muscle volumes were measured. To determine HRQoL at baseline and at 2-year follow-up, face-to-face questionnaires were administered, which included visual analogue scale of the back and leg, physical component summary/mental component summary of 36-item Short Form Health Survey, Oswestry Disability Index (ODI), and Mini-Mental State Examination.
Results Overall HRQoL measures had improved after 2 years of follow-up compared to baseline. PDSI aggravation was observed in 18 participants (26.1%). TLS, sagittal vertical axis (SVA), and T1PA were strongly correlated with each other. TLS, SVA, and T1PA were correlated with ODI score. Among them, TLS was most highly correlated with ODI score. TLS greater than -3.5° was a predicting factor for PDSI aggravation (p=0.034; 95% confidence interval, 1.173–63.61; odds ratio, 8.636).
Conclusion The present study implied that PDSI does not necessarily worsen with aging. TLS is an appropriate parameter for assessing the clinical situation in patients with PDSI. Furthermore, a TLS greater than -3.5° predicts PDSI aggravation; thus, TLS may be a useful parameter for predicting prognosis in PDSI.
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Affiliation(s)
- Bong Ju Moon
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Moon-Soo Han
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jae-Young Kim
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
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Ham DW, Kim HJ, Choi JH, Park J, Lee J, Yeom JS. Validity of the global alignment proportion (GAP) score in predicting mechanical complications after adult spinal deformity surgery in elderly patients. 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 2021; 30:1190-1198. [PMID: 33528658 DOI: 10.1007/s00586-021-06734-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE This study aimed to validate the usefulness of the global alignment proportion (GAP) score to predict postoperative mechanical failure in the elderly (mean age, 70.5 years) individuals with severe sagittal imbalance. METHODS A total of 84 patients were enrolled: mechanical complications (MC), minor mechanical complications (mMC), proximal junctional failure (PJF), and revision surgery occurred in 61% (51/84), 58% (49/84), 44% (37/84), and 13% (11/84) of the patients, respectively. The GAP score was calculated using the X-ray obtained in the early postoperative period. The validity of the GAP score's predictive ability was evaluated by calculating the area under the curve (AUC) of the receiver operating characteristics curve. Univariate logistic regression analysis and Cochran-Armitage test of trend were performed to determine the association between mechanical complications and GAP score. RESULTS The discriminatory power of GAP score to predict MC, mMC, and PJF was "moderately accurate," with an AUC of 0.839 (confidence interval [CI] 0.755-0.824, p < 0.001), 0.836 (CI 0.749-0.923, p < 0.001), and 0.702 (CI 0.588-0.851, p < 0.001), respectively. The GAP score showed a statistically significant association with MC, mMC, and PJF in univariate logistic regression analysis and Cochran-Armitage test for trend. However, it was not significantly associated with revision surgery. CONCLUSION This study showed promising results regarding the GAP score's predictive power for MC, mMC, and PJF in the elderly population with degenerative kyphoscoliosis. Using the GAP score, we can determine the patient's specific correction goal preoperatively to prevent mechanical failure based on individual patient's characteristics such as pelvic incidence.
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Affiliation(s)
- Dae-Woong Ham
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Seoul National University Bundang Hospital, 166 Gumiro Bundang-gu, Seongnam, 463-707, Republic of Korea.
| | - Jae Heouk Choi
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Park
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Junpyo Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin S Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Patel M, Kasliwal MK. Commentary: Thoracolumbar Junction Orientation: A Novel Guide for Sagittal Correction and Proximal Junctional Kyphosis Prediction in Adult Spinal Deformity Patients. Neurosurgery 2020; 88:E27-E28. [PMID: 32761188 DOI: 10.1093/neuros/nyaa349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/21/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohit Patel
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western University School of Medicine, Cleveland, Ohio
| | - Manish K Kasliwal
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western University School of Medicine, Cleveland, Ohio
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