1
|
Tani Y, Naka N, Ono N, Kawashima K, Paku M, Ishihara M, Adachi T, Ando M, Taniguchi S, Saito T. Can We Rely on Prophylactic Two-Level Vertebral Cement Augmentation in Long-Segment Adult Spinal Deformity Surgery to Reduce the Incidence of Proximal Junctional Complications? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:860. [PMID: 38929477 PMCID: PMC11205771 DOI: 10.3390/medicina60060860] [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: 03/28/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods: The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results: With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions: Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-City 573-1010, Japan; (Y.T.); (N.N.); (N.O.); (K.K.); (M.P.); (M.I.); (T.A.); (M.A.); (S.T.)
| |
Collapse
|
2
|
Passias PG, Williamson TK, Joujon-Roche R, Krol O, Tretiakov P, Imbo B, Schoenfeld AJ, Owusu-Sarpong S, Lebovic J, Mir J, Dave P, McFarland K, Vira S, Diebo BG, Park P, Chou D, Smith JS, Lafage R, Lafage V. The Impact of Lumbopelvic Realignment Versus Prevention Strategies at the Upper-instrumented Vertebra on the Rates of Junctional Failure Following Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E72-E78. [PMID: 37235802 DOI: 10.1097/brs.0000000000004732] [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: 10/21/2022] [Accepted: 02/06/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN/SETTING Retrospective. OBJECTIVE Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery. SUMMARY OF BACKGROUND DATA Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates. MATERIALS AND METHODS ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders. RESULTS In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049). CONCLUSION To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Peter Tretiakov
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Bailey Imbo
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | | | - Jordan Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Jamshaid Mir
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Pooja Dave
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Kimberly McFarland
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, TN
| | - Dean Chou
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Wu J, Miao J, Chen G, Xu H, Wen W, Xu H, Liu L. Finite element biomechanical analysis of 3D printed intervertebral fusion cage in osteoporotic population. BMC Musculoskelet Disord 2024; 25:129. [PMID: 38347518 PMCID: PMC10860281 DOI: 10.1186/s12891-024-07221-7] [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: 08/10/2023] [Accepted: 01/21/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE To study the biomechanical characteristics of each tissue structure when using different 3D printing Cage in osteoporotic patients undergoing interbody fusion. METHODS A finite element model of the lumbar spine was reconstructed and validated with regarding a range of motion and intervertebral disc pressure from previous in vitro studies. Cage and pedicle screws were implanted and part of the lamina, spinous process, and facet joints were removed in the L4/5 segment of the validated mode to simulate interbody fusion. A 280 N follower load and 7.5 N·m moment were applied to different postoperative models and intact osteoporotic model to simulate lumbar motion. The biomechanical characteristics of different models were evaluated by calculating and analyzing the range of motion of the fixed and cephalic adjacent segment, the stress of the screw-rod system, the stress at the interface between cage and L5 endplate, and intervertebral disc pressure of the adjacent segment. RESULTS After rigid fixation, the range of motion of the fixed segment of model A-C decreased significantly, which was much smaller than that of the osteoporotic model. And with the increase of the axial area of the interbody fusion cages, the fixed segment of model A-C tended to be more stable. The range of motion and intradiscal pressure of the spinal models with different interbody fusion cages were higher than those of the complete osteoporosis model, but there was no significant difference between the postoperative models. On the other hand, the L5 upper endplate stress and screw-rod system stress of model A-C show a decreasing trend in different directions of motion. The stress of the endplate is the highest during flexion, which can reach 40.5 MPa (model A). The difference in endplate stress between models A-C was the largest during lateral bending. The endplate stress of models A and B was 150.5% and 140.9% of that of model C, respectively. The stress of the screw-rod system was the highest during lateral bending (model A, 102.0 MPa), which was 108.4%, 102.4%, 110.4%, 114.2% of model B and 158.5%, 110.1%, 115.8%, 125.4% of model C in flexion, extension, lateral bending, and rotation, respectively. CONCLUSIONS For people with osteoporosis, no matter what type of cage is used, good immediate stability can be achieved after surgery. Larger cage sizes provide better fixation without significantly increasing ROM and IDP in adjacent segments, which may contribute to the development of ASD. In addition, larger cage sizes can disperse endplate stress and reduce stress concentration, which is of positive significance in preventing cage subsidence after operation. The cage and screw rod system establish a stress conduction pathway on the spine, and a larger cage greatly enhances the stress-bearing capacity of the front column, which can better distribute the stress of the posterior spine structure and the stress borne by the posterior screw rod system, reduce the stress concentration phenomenon of the nail rod system, and avoid exceeding the yield strength of the material, resulting in the risk of future instrument failure.
Collapse
Affiliation(s)
- Jincheng Wu
- Department of Emergency Trauma Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China, 48 Baishuitang Road, Longhua District, 571700
| | - Jun Miao
- Tianjin Hospital, Tianjin University, Tianjin, China
| | | | - Hanpeng Xu
- Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wangqiang Wen
- The First Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China
| | - Haoxiang Xu
- The Second People's Hospital of Hefei, Hefei, Anhui, China
| | - Lizhu Liu
- Department of Emergency Trauma Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China, 48 Baishuitang Road, Longhua District, 571700.
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
Anderson B, Shahidi B. The Impact of Spine Pathology on Posterior Ligamentous Complex Structure and Function. Curr Rev Musculoskelet Med 2023; 16:616-626. [PMID: 37870725 PMCID: PMC10733250 DOI: 10.1007/s12178-023-09873-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE OF REVIEW Spinal ligament is an important component of the spinal column in mitigating biomechanical stress. Particularly the posterior ligamentous complex, which is composed of the ligamentum flavum, interspinous, and supraspinous ligaments. However, research characterizing the biomechanics and role of ligament health in spinal pathology and clinical context are scarce. This article provides a comprehensive review of the implications of spinal pathology on the structure, function, and biomechanical properties of the posterior ligamentous complex. RECENT FINDINGS Current research characterizing biomechanical properties of the posterior ligamentous complex is primarily composed of cadaveric studies and finite element modeling, and more recently incorporating patient-specific anatomy into finite element models. The ultimate goal of current research is to understand the relative contributions of these ligamentous structures in healthy and pathological spine, and whether preserving ligaments may play an important role in spinal surgical techniques. At baseline, posterior ligamentous complex structures account for 30-40% of spinal stability, which is highly dependent on the intrinsic biomechanical properties of each ligament. Biomechanics vary widely with pathology and following rigid surgical fixation techniques and are generally maladaptive. Often secondary to morphological changes in the setting of spinal pathology, but morphological changes in ligament may also serve as a primary pathology. Biomechanical maladaptations of the spinal ligament adversely influence overall spinal column integrity and ultimately predispose to increased risk for surgical failure and poor clinical outcomes. Future research is needed, particularly in living subjects, to better characterize adaptations in ligaments that can provide targets for improved treatment of spinal pathology.
Collapse
Affiliation(s)
- Bradley Anderson
- Department of Orthopaedic Surgery, The University of California San Diego, 9500 Gilman Dr., MC0863, La Jolla, San Diego, CA, 92093, USA
| | - Bahar Shahidi
- Department of Orthopaedic Surgery, The University of California San Diego, 9500 Gilman Dr., MC0863, La Jolla, San Diego, CA, 92093, USA.
| |
Collapse
|
7
|
Passias PG, Krol O, Williamson TK, Lafage V, Lafage R, Smith JS, Line B, Vira S, Lipa S, Daniels A, Diebo B, Schoenfeld A, Gum J, Kebaish K, Park P, Mundis G, Hostin R, Gupta MC, Eastlack R, Anand N, Ames C, Hart R, Burton D, Schwab FJ, Shaffrey C, Klineberg E, Bess S. The Benefit of Addressing Malalignment in Revision Surgery for Proximal Junctional Kyphosis Following ASD Surgery. Spine (Phila Pa 1976) 2023; 48:1581-1587. [PMID: 36083599 DOI: 10.1097/brs.0000000000004476] [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: 02/08/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch. MATERIALS AND METHODS Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]. RESULTS A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001). CONCLUSIONS Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.
Collapse
Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Oscar Krol
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shaleen Vira
- Department of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Shaina Lipa
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, RI
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD
| | - Paul Park
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Robert Eastlack
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Blais M, Shahidi B, Anderson B, O'Brien E, Moltzen C, Iannacone T, Eastlack RK, Mundis GM. The influence of ligament biomechanics on proximal junctional kyphosis and failure in patients with adult spinal deformity. JOR Spine 2023; 6:e1277. [PMID: 37780835 PMCID: PMC10540824 DOI: 10.1002/jsp2.1277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/04/2023] [Accepted: 08/03/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose It is unknown whether the biomechanics of the posterior ligamentous complex (PLC) are impaired in individuals undergoing surgery for adult spinal deformity (ASD). Characterizing these properties may improve our understanding of proximal junctional kyphosis (PJK; defined as proximal junctional angle [PJA] of >10 deg from UIV-1 to UIV + 2), as well as proximal junctional failure (PJF; symptomatic PJK requiring revision). The purpose of this prospective observational study is to compare biomechanical properties of the PLC in individuals with ASD who do, and do not develop PJK or PJF within 1 year of spinal fusion surgery. Methods Intraoperative biopsies of PLC were obtained from 32 consecutive patients undergoing spinal fusions for ASD (>4 levels). Ligament peak force, tensile stress, tensile strain, and elastic modulus (EM) were measured with a materials testing system. Biomechanical properties and tissue dimensions were correlated with age, gender, BMI, vitamin D level, osteoporosis, sagittal alignment, PJA and change in PJA preoperatively, within 3 months, and at 1 year postoperatively. Results Longer ligaments were associated with greater PJA change at 3 months (p = 0.04), and thinner ligaments were associated with greater PJA change at 1 year (r = 0.57, p = 0.01). Greater EM was associated with greater PJA at both 3 months and 1 year (p = 0.03). Five participants had a change in PJA of >10 1 year postoperatively, and three participants demonstrated PJF. EM was significantly higher in individuals who required revision surgery (p = 0.003), and ligament length was greater (p = 0.03). Preoperative sagittal alignment was not related to incidence of revision surgery (p > 0.10). Conclusions The biomechanical properties of the PLC may be associated with higher risk for proximal failure. Ligaments that are longer, thinner, and less elastic are associated with higher postoperative PJA. Furthermore stiffer EM of the ligament is associated with the need for revision surgery.
Collapse
Affiliation(s)
- Micah Blais
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Bahar Shahidi
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Brad Anderson
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Eli O'Brien
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Courtney Moltzen
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Tina Iannacone
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Robert K. Eastlack
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Gregory M. Mundis
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| |
Collapse
|
10
|
Wang J, Geng Z, Wu J, Liu J, Zhang Z, Miao J, Li R. Biomechanical properties of lumbar vertebral ring apophysis cage under endplate injury: a finite element analysis. BMC Musculoskelet Disord 2023; 24:695. [PMID: 37649054 PMCID: PMC10466841 DOI: 10.1186/s12891-023-06792-1] [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: 05/09/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE This study aimed to compare the biomechanical properties of lumbar interbody fusion involving two types of cages. The study evaluated the effectiveness of the cage spanning the ring apophysis, regardless of the endplate's integrity. METHODS A finite element model of the normal spine was established and validated in this study. The validated model was then utilized to simulate Lateral Lumbar Interbody Fusion (LLIF) with posterior pedicle screw fixation without posterior osteotomy. Two models of interbody fusion cage were placed at the L4/5 level, and the destruction of the bony endplate caused by curetting the cartilaginous endplate during surgery was simulated. Four models were established, including Model 1 with an intact endplate and long cage spanning the ring apophysis, Model 2 with endplate decortication and long cage spanning the ring apophysis, Model 3 with an intact endplate and short cage, and Model 4 with endplate decortication and short cage. Analyzed were the ROM of the fixed and adjacent segments, screw rod system stress, interface stress between cage and L5 endplate, trabecular bone stress on the upper surface of L5, and intervertebral disc pressure (IDP) of adjacent segments. RESULTS There were no significant differences in ROM and IDP between adjacent segments in each postoperative model. In the short cage model, the range of motion (ROM), contact pressure between the cage and endplate, stress in L5 cancellous bone, and stress in the screw-rod system all exhibited an increase ranging from 0.4% to 79.9%, 252.9% to 526.9%, 27.3% to 133.3%, and 11.4% to 107%, respectively. This trend was further amplified when the endplate was damaged, resulting in a maximum increase of 88.6%, 676.1%, 516.6%, and 109.3%, respectively. Regardless of the integrity of the endplate, the long cage provided greater support strength compared to the short cage. CONCLUSIONS Caution should be exercised during endplate preparation and cage placement to maintain the endplate's integrity. Based on preoperative X-ray evaluation, the selection of a cage that exceeds the width of the pedicle by at least 5 mm (ensuring complete coverage of the vertebral ring) has demonstrated remarkable biomechanical performance in lateral lumbar interbody fusion procedures. By opting for such a cage, we expect a reduced occurrence of complications, including cage subsidence, internal fixation system failure, and rod fracture.
Collapse
Affiliation(s)
- Jian Wang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Ziming Geng
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jincheng Wu
- The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China
| | - Jianchao Liu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Zepei Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jun Miao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China.
| | - Ruihua Li
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China.
| |
Collapse
|
11
|
Takeda H, Abe Y, Imai T, Rashid MZM, Ikeda D, Kawabata S, Nagai S, Hachiya K, Fujita N, Kaneko S. Elucidation of the Mechanism of Occasional Anterior Longitudinal Ligament Rupture with Posterior Correction Procedure for Adult Spinal Deformity Using LLIF-Finite Element Analysis of the Impact of the Lordotic Angle of Intervertebral LLIF Cage. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1569. [PMID: 37763688 PMCID: PMC10532993 DOI: 10.3390/medicina59091569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: There are several advantages of using lateral lumbar interbody fusion (LLIF) for correction surgeries for adult spinal deformity (ASD); however, we currently have unresolved new issues, including occasional anterior longitudinal ligament (ALL) rupture during the posterior correction procedure. When LLIF was initially introduced, only less lordotic cages were available and ALL rupture was more frequently experienced compared with later periods when more lordotic cages were available. We performed finite element analysis (FEA) regarding the mechanism of ALL rupture during a posterior correction procedure. Methods: A spring (which mimics ALL) was introduced at the location of ALL in the FEA and an LLIF cage with two different lordotic angles, 6 and 12 degrees (6DC/12DC), was employed. To assess the extent of burden on the ALL, the extension length of the spring during the correction procedure was measured and the location of the rotation center was examined. Results: We observed a significantly higher degree of length extension of the spring during the correction procedure in the FEA model with 6DC compared with that of 12DC. We also observed that the location of the rotation center was shifted posteriorly in the FEA model with 6DC compared with that of 12DC. Conclusions: It is considered that the posterior and rostral edge of the less lordotic angle cage became a hinge, and the longer lever arm increased the burden on ALL as the principle of leverage. It is important to use an LLIF cage with a sufficient lordotic angle, that is compatible with the degree of posterior osteotomy in ASD correction.
Collapse
Affiliation(s)
- Hiroki Takeda
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan
| | - Yuichiro Abe
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan
- Department of Orthopedic Surgery, Eniwa Hospital, Eniwa 061-1373, Japan
| | - Takaya Imai
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Mohd Zaim Mohd Rashid
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan
| | - Daiki Ikeda
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Soya Kawabata
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Sota Nagai
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Kurenai Hachiya
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Shinjiro Kaneko
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan
| |
Collapse
|
12
|
van Agtmaal JL, Doodkorte RJP, Roth AK, Ito K, Arts JJC, Willems PC, van Rietbergen B. Biomechanical evaluation of different semi-rigid junctional fixation techniques using finite element analysis. Clin Biomech (Bristol, Avon) 2023; 108:106071. [PMID: 37597385 DOI: 10.1016/j.clinbiomech.2023.106071] [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: 04/24/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Proximal junctional failure is a common complication attributed to the rigidity of long pedicle screw fixation constructs used for surgical correction of adult spinal deformity. Semi-rigid junctional fixation achieves a gradual transition in range of motion at the ends of spinal instrumentation, which could lead to reduced junctional stresses, and ultimately reduce the incidence of proximal junctional failure. This study investigates the biomechanical effect of different semi-rigid junctional fixation techniques in a T8-L3 finite element spine segment model. METHODS First, degeneration of the intervertebral disc was successfully implemented by altering the height. Second, transverse process hooks, one- and two-level clamped tapes, and one- and two-level knotted tapes instrumented proximally to three-level pedicle screw fixation were validated against ex vivo range of motion data of a previous study. Finally, the posterior ligament complex forces and nucleus pulposus stresses were quantified. FINDINGS Simulated range of motions demonstrated the fidelity of the general model and modelling of semi-rigid junctional fixation techniques. All semi-rigid junctional fixation techniques reduced the posterior ligament complex forces at the junctional zone compared to pedicle screw fixation. Transverse process hooks and knotted tapes reduced nucleus pulposus stresses, whereas clamped tapes increased nucleus pulposus stresses at the junctional zone. INTERPRETATION The relationship between the range of motion transition and the reductions in posterior ligament complex and nucleus pulposus stresses was complex and dependent on the fixation techniques. Clinical trials are required to compare the effectiveness of semi-rigid junctional fixation techniques in terms of reducing proximal junctional failure incidence rates.
Collapse
Affiliation(s)
- Julia L van Agtmaal
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Den Dolech 2, 5612AZ Eindhoven, the Netherlands; Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Remco J P Doodkorte
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Alex K Roth
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Keita Ito
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Den Dolech 2, 5612AZ Eindhoven, the Netherlands
| | - Jacobus J C Arts
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Den Dolech 2, 5612AZ Eindhoven, the Netherlands; Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Paul C Willems
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Bert van Rietbergen
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Den Dolech 2, 5612AZ Eindhoven, the Netherlands; Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229HX Maastricht, the Netherlands.
| |
Collapse
|
13
|
Lazaro B, Sardi JP, Smith JS, Kelly MP, Yanik EL, Dial B, Hills J, Gupta MC, Baldus CR, Yen CP, Lafage V, Ames CP, Bess S, Schwab F, Shaffrey CI, Bridwell KH. Proximal junctional failure in primary thoracolumbar fusion/fixation to the sacrum/pelvis for adult symptomatic lumbar scoliosis: long-term follow-up of a prospective multicenter cohort of 160 patients. J Neurosurg Spine 2023; 38:319-330. [PMID: 36334285 DOI: 10.3171/2022.9.spine22549] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/30/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Proximal junctional failure (PJF) is a severe form of proximal junctional kyphosis. Previous reports on PJF have been limited by heterogeneous cohorts and relatively short follow-ups. The authors' objectives herein were to identify risk factors for PJF and to assess its long-term incidence and revision rates in a homogeneous cohort. METHODS The authors reviewed data from the Adult Symptomatic Lumbar Scoliosis 1 trial (ASLS-1), a National Institutes of Health-sponsored prospective multicenter study. Inclusion criteria were an age ≥ 40 years, ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society revised 22-item questionnaire [SRS-22r] score ≤ 4.0 in pain, function, or self-image domains), and primary thoracolumbar fusion/fixation to the sacrum/pelvis of ≥ 7 levels. PJF was defined as a postoperative proximal junctional angle (PJA) change > 20°, fracture of the uppermost instrumented vertebra (UIV) or UIV+1 with > 20% vertebral height loss, spondylolisthesis of UIV/UIV+1 > 3 mm, or UIV screw dislodgment. RESULTS One hundred sixty patients (141 women) were included in this analysis and had a median age of 62 years and a mean follow-up of 4.3 years (range 0.1-6.1 years). Forty-six patients (28.8%) had PJF at a median of 0.92 years (IQR 0.14, 1.23 years) following surgery. Based on Kaplan-Meier analyses, PJF rates at 1, 2, 3, and 4 years were 14.4%, 21.9%, 25.9%, and 27.4%, respectively. On univariate analysis, PJF was associated with greater age (p = 0.0316), greater body mass index (BMI; p = 0.0319), worse baseline patient-reported outcome measures (PROMs; ODI, SRS-22r, and SF-12 Physical Component Summary [PCS]; all p < 0.04), the use of posterior column osteotomies (PCOs; p = 0.0039), and greater postoperative thoracic kyphosis (TK; p = 0.0031) and PJA (p < 0.001). The use of UIV hooks was protective against PJF (p = 0.0340). On regression analysis (without postoperative measures), PJF was associated with greater BMI (HR 1.077, 95% CI 1.007-1.153, p = 0.0317), lower preoperative PJA (HR 0.607, 95% CI 0.407-0.906, p = 0.0146), and greater preoperative TK (HR 1.362, 95% CI 1.082-1.715, p = 0.0085). Patients with PJF had worse PROMs at the last follow-up (ODI, SRS-22r subscore and self-image, and SF-12 PCS; p < 0.04). Sixteen PJF patients (34.8%) underwent revision, and PJF recurred in 3 (18.8%). CONCLUSIONS Among 160 primary ASLS patients with a median age of 62 years and predominant coronal deformity, the PJF rate was 28.8% at a mean 4.3-year follow-up, with a revision rate of 34.8%. On univariate analysis, PJF was associated with a greater age and BMI, worse baseline PROMs, the use of PCOs, and greater postoperative TK and PJA. The use of UIV hooks was protective against PJF. On multivariate analysis (without postoperative measures), a higher risk of PJF was associated with greater BMI and preoperative TK and lower preoperative PJA.
Collapse
Affiliation(s)
- Bruno Lazaro
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Juan Pablo Sardi
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael P Kelly
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elizabeth L Yanik
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brian Dial
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Hills
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Munish C Gupta
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine R Baldus
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Chun Po Yen
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Christopher P Ames
- 4Department of Neurosurgery, University of California, San Francisco, California
| | - Shay Bess
- 5Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | | | - Christopher I Shaffrey
- and Departments of6Neurosurgery and
- 7Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Keith H Bridwell
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
14
|
Wu J, Feng Q, Yang D, Xu H, Wen W, Xu H, Miao J. Biomechanical evaluation of different sizes of 3D printed cage in lumbar interbody fusion-a finite element analysis. BMC Musculoskelet Disord 2023; 24:85. [PMID: 36726086 PMCID: PMC9890703 DOI: 10.1186/s12891-023-06201-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/27/2023] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To study the biomechanical characteristics of various tissue structures of different sizes of 3D printed Cage in lumbar interbody fusion. METHODS A finite element model of normal spine was reconstructed and verified. Pedicle screws and Cage of different sizes were implanted in the L4/5 segment to simulate lumbar interbody fusion. The range of motion of the fixed and cephalic adjacent segment, the stress of the screw-rod system, the stress at the interface between cage and L5 endplate, and intervertebral disc pressure of the adjacent segment were calculated and analyzed. RESULTS The range of motion and intervertebral disc pressure of the adjacent segment of each postoperative model were larger than those of the intact model, but there was not much difference between them. The stress of cage-endplate interface was also larger than that of the intact model. However, the difference is that the stress of the endplate and the screw-rod system has a tendency to decrease with the increase of the axial area of cage. CONCLUSIONS Cage with larger axial area in lumbar interbody fusion can reduce the stress of internal fixation system and endplate, but will not increase the range of motion and intervertebral disc pressure of adjacent segment. It has a certain effect in preventing the cage subsidence, internal fixation system failure and screw rod fracture.
Collapse
Affiliation(s)
- Jincheng Wu
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, China
| | - Qing Feng
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, China
| | - Dongmei Yang
- grid.284723.80000 0000 8877 7471Southern Medical University, Guangzhou City, Guangdong China
| | - Hanpeng Xu
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, China
| | - Wangqiang Wen
- grid.443397.e0000 0004 0368 7493The First Affiliated Hospital of Hainan Medical University, Haikou City, Hainan China
| | - Haoxiang Xu
- The Second People’s Hospital of Hefei, Hefei, Anhui China
| | - Jun Miao
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, China
| |
Collapse
|
15
|
Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness. Spine Deform 2023; 11:59-69. [PMID: 36083461 DOI: 10.1007/s43390-022-00574-w] [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: 03/31/2022] [Accepted: 08/13/2022] [Indexed: 10/14/2022]
Abstract
STUDY DESIGN Assessment of different proximal instrumentation stiffness features to minimize the mechanical proximal junctional failure-related risks through computer-based biomechanical models. OBJECTIVE To biomechanically assess variations of proximal instrumentation and loads acting on the spine and construct to minimize proximal junctional failure (PJF) risks. The use of less-stiff fixation such as hooks or tensioned bands, compared to pedicle screws, at the proximal instrumentation level are considered to allow for a gradual transition in stiffness with the adjacent levels, but the impact of such flexible fixation on the loads balance and complications such as PJF remain uncertain. METHODS Six patients with adult spine deformity who underwent posterior spinal instrumentation were used to numerically model and simulate the surgical steps, erected posture, and flexion functional loading in patient-specific multibody analyses. Three types of upper-level fixation (pedicle screws (PS), supralaminar hooks (SH), and sublaminar bands (SB) with tensions of 50, 250, and 350 N) and rod stiffness (CoCr/6 mm, CoCr/5.5 mm, Ti/5.5 mm) were simulated. The loads acting on the spine and implants of the 90 simulated configurations were analyzed using Kruskal-Wallis statistical tests. RESULTS Simulated high-tensioned bands decreased the sagittal moment at the adjacent level proximal to the instrumentation (1.3 Nm at 250 N; 2.5 Nm at 350 N) compared to screws alone (PS) (15.6 Nm). At one level above, the high-tensioned SB increased the sagittal moment (17.7 Nm-SB vs. 15.5 Nm-PS) and bending moment on the rods (5.4 Nm and 5.7 Nm vs. 0.6 Nm) (p < 0.05). SB with 50 N tension yielded smaller changes in load transition compared to higher tension, with moments of 8.1 Nm and 16.8 Nm one and two levels above the instrumentation. The sagittal moment at the upper implant-vertebra connection decreased with the rod stiffness (1.0 Nm for CoCr/6 mm vs. 0.7 Nm for Ti/5.5 mm; p < 0.05). CONCLUSION Simulated sublaminar bands with lower tension produced smaller changes in the load transition across proximal junctional levels. Decreasing the rod stiffness further modified these changes, with a decrease in loads associated with bone failure, however, lower stiffness did increase the rod breakage risk. LEVEL OF EVIDENCE N/A.
Collapse
|
16
|
Park BJ, Gold CJ, Christianson D, DeVries Watson NA, Nourski KV, Woodroffe RW, Hitchon PW. Biomechanical assessment of the effect of sublaminar band tensioning on lumbar motion. J Neurosurg Spine 2022; 37:836-842. [PMID: 35901707 DOI: 10.3171/2022.5.spine22371] [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: 04/02/2022] [Accepted: 05/16/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Adjacent-segment disease (ASD) proximal to lumbosacral fusion is assumed to result from increased stress and motion that extends above or below the fusion construct. Sublaminar bands (SBs) have been shown to potentially mitigate stresses in deformity constructs. A similar application of SBs in lumbar fusions is not well described yet may potentially mitigate against ASD. METHODS Eight fresh-frozen human cadaveric spine specimens were instrumented with transforaminal lumbar interbody fusion (TLIF) cages at L3-4 and L4-5, and pedicle screws from L3 to S1. Bilateral SBs were applied at L2 and tightened around the rods extending above the L3 pedicle screws. After being mounted on a testing frame, the spines were loaded at L1 to 6 Nm in all 3 planes, i.e., flexion/extension, right and left lateral bending, and right and left axial rotation. Motion and intradiscal pressures (IDPs) at L2-3 were measured for 5 conditions: intact, instrumentation (L3-S1), band tension (BT) 30%, BT 50%, and BT 100%. RESULTS There was significant increase in motion at L2-3 with L3-S1 instrumentation compared with the intact spine in flexion/extension (median 8.78°, range 4.07°-10.81°, vs median 7.27°, range 1.63°-9.66°; p = 0.016). When compared with instrumentation, BT 100% reduced motion at L2-3 in flexion/extension (median 8.78°, range 4.07°-10.81°, vs median 3.61°, range 1.11°-9.39°; p < 0.001) and lateral bending (median 6.58°, range 3.67°-8.59°, vs median 5.62°, range 3.28°-6.74°; p = 0.001). BT 50% reduced motion at L2-3 only in flexion/extension when compared with instrumentation (median 8.78°, range 4.07°-10.81°, vs median 5.91°, range 2.54°-10.59°; p = 0.027). There was no significant increase of motion at L1-2 with banding when compared with instrumentation, although an increase was seen from the intact spine with BT 100% in flexion/extension (median 5.14°, range 2.47°-9.73°, vs median 7.34°, range 4.22°-9.89°; p = 0.005). BT 100% significantly reduced IDP at L2-3 from 25.07 psi (range 2.41-48.08 psi) before tensioning to 19.46 psi (range -2.35 to 29.55 psi) after tensioning (p = 0.016). CONCLUSIONS In this model, the addition of L2 SBs reduced motion and IDP at L2-3 after the L3-S1 instrumentation. There was no significant increase in motion at L1-2 in response to band tensioning compared with instrumentation alone. The application of SBs may have a clinical application in reducing the incidence of ASD.
Collapse
Affiliation(s)
| | | | | | | | - Kirill V Nourski
- Departments of1Neurosurgery and.,3Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa
| | | | | |
Collapse
|
17
|
Biomechanical Comparison of Multilevel Lumbar Instrumented Fusions in Adult Spinal Deformity According to the Upper and Lower Fusion Levels: A Finite Element Analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2534350. [PMID: 36506913 PMCID: PMC9729043 DOI: 10.1155/2022/2534350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Abstract
Multilevel lumbar fusion with posterior pedicle screw fixation is a widely performed surgical procedure for the management of adult spinal deformity. However, there has not been a comprehensive biomechanical study on the different types of fusion levels in terms of stability and possible complications. We aimed to investigate the biomechanical properties of multilevel lumbar fusion according to different types of upper and lower fusion levels. Six different types of fusions were performed using three-dimensional finite element models. Type A and B referred to the group of which upper fusion level was L1 and T10, respectively. Subtype 1, 2, and 3 referred to the group of which lower fusion level was L5, S1, and ilium, respectively (A1, L1-L5; A2, L1-S1; A3, L1-ilium; B1, T10-L5; B2, T10-S1; B3, T10-ilium). Flexion, extension, axial rotation, and lateral bending moments were applied, and the risk of screw loosening and failure and adjacent segment degeneration (ASD) was analyzed. Stress at the bone-screw interface of type B3 was lowest in overall motions. The risk of screw failure showed increasing pattern as the upper and lower levels extended in all motions. Proximal range of motion (ROM) increased as the lower fusion level changed from L5 to S1 and the ilium. For axial rotation, type B3 showed higher proximal ROM (16.2°) than type A3 (11.8°). In multilevel lumbar fusion surgery for adult spinal deformity, adding iliac screws and increasing the fusion level to T10-ilium may lower the risk of screw loosening. In terms of screw failure and proximal ASD, however, T10-ilium fusion has a higher potential risk compared with other fusion types. These results will contribute for surgeons to provide adequate patient education regarding screw failure and proximal ASD, when performing multilevel lumbar fusion.
Collapse
|
18
|
Zhang TT, Ding JZ, Kong C, Zhu WG, Wang SK, Lu SB. Paraspinal muscle degeneration and lower bone mineral density as predictors of proximal junctional kyphosis in elderly patients with degenerative spinal diseases: a propensity score matched case–control analysis. BMC Musculoskelet Disord 2022; 23:1010. [DOI: 10.1186/s12891-022-05960-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/23/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Study design
Retrospective case–control study.
Objectives
Proximal junctional kyphosis (PJK) is a postoperative complication involving the proximal segments which is commonly seen in patients with degenerative spine diseases (DSD). The purpose of the present study was to identify predictive factors for postoperative PJK in elderly patients with DSD.
Methods
We reviewed elderly patients with DSD who underwent thoracolumbar fusion involving no less than 3 levels. Patients who developed PJK were propensity score-matched with patients with DSD who received the same procedure but did not develop PJK. Demographic characteristics, sagittal vertical axis (SVA), computed tomography (CT) value (Hounsfield unit), and paraspinal muscle parameters were compared between PJK and non-PJK groups.
Results
Eighty-three PJK and non-PJK patients were selected by propensity score matching for age, sex, history of smoking, body mass index, number of fused segments, and upper instrumented vertebra (UIV) location. SVA showed no significant difference between the two groups. In PJK group, fatty infiltration (FI) in erector spinae and multifidus was significantly greater, while the relative cross-sectional area (rCSA) of erector spinae was significantly smaller than that in non-PJK group. CT value was significantly lower in PJK group. Lower erector spinae rCSA and CT value of the UIV, higher erector spinae FI and multifidus FI were identified as predictors of postoperative PJK.
Conclusions
PJK is a common complication in older patients with DSD. Paraspinal muscle degeneration and low bone mineral density of the UIV are predictors of PJK. Protective measures targeting paraspinal muscles and the UIV may help prevent postoperative PJK.
Collapse
|
19
|
Liu W, Zang L, Kang N, Yang L, An L, Zhu W, Hai Y. Influence of configuration and anchor in ligamentous augmentation to prevent proximal junctional kyphosis: A finite element study. Front Bioeng Biotechnol 2022; 10:1014487. [DOI: 10.3389/fbioe.2022.1014487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Ligament augmentation has been applied during spinal surgery to prevent proximal junctional kyphosis (PJK), but the configuration and distal anchor strategies are diverse and inconsistent. The biomechanics of different ligament augmentation strategies are, therefore, unclear. We aimed to create a finite element model of the spine for segments T6–S1. Model Intact was the native form, and Model IF was instrumented with a pedicle screw from segments T10 to S1. The remaining models were based on Model IF, with ligament augmentation configurations as common (CM), chained (CH), common and chained (CHM); and distal anchors to the spinous process (SP), crosslink (CL), and pedicle screw (PS), creating SP-CH, PS-CHM, PS-CH, PS-CM, CL-CHM, CL-CH, and CL-CM models. The range of motion (ROM) and maximum stress on the intervertebral disc (IVD), PS, and interspinous and supraspinous ligaments (ISL/SSL) was measured. In the PS-CH model, the ROM for segments T9–T10 was 73% (of Model Intact). In the CL-CHM, CL-CH, CL-CM, PS-CM, and PS-CHM models, the ROM was 8%, 17%, 7%, 13%, and 30%, respectively. The PS-CH method had the highest maximum stress on IVD and ISL/SSL, at 80% and 72%, respectively. The crosslink was more preferable as the distal anchor. In the uppermost instrumented vertebrae (UIV) + 1/UIV segment, the CM was the most effective configuration. The PS-CH model had the highest flexion load on the UIV + 1/UIV segment and the CL-CM model provided the greatest reduction. The CL-CM model should be verified in a clinical trial. The influence of configuration and anchor in ligament augmentation is important for the choice of surgical strategy and improvement of technique.
Collapse
|
20
|
Elias E, Bess S, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias PG, Nasser Z, Gum JL, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Gupta M, Hart R, Schwab FJ, Burton D, Ames CP, Shaffrey CI, Smith JS. Outcomes of operative treatment for adult spinal deformity: a prospective multicenter assessment with mean 4-year follow-up. J Neurosurg Spine 2022; 37:607-616. [PMID: 35535835 DOI: 10.3171/2022.3.spine2295] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The current literature has primarily focused on the 2-year outcomes of operative adult spinal deformity (ASD) treatment. Longer term durability is important given the invasiveness, complications, and costs of these procedures. The aim of this study was to assess minimum 3-year outcomes and complications of ASD surgery. METHODS Operatively treated ASD patients were assessed at baseline, follow-up, and through mailings. Patient-reported outcome measures (PROMs) included scores on the Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r) questionnaire, mental component summary (MCS) and physical component summary (PCS) of the SF-36, and numeric rating scale (NRS) for back and leg pain. Complications were classified as perioperative (≤ 90 days), delayed (90 days to 2 years), and long term (≥ 2 years). Analyses focused on patients with minimum 3-year follow-up. RESULTS Of 569 patients, 427 (75%) with minimum 3-year follow-up (mean ± SD [range] 4.1 ± 1.1 [3.0-9.6] years) had a mean age of 60.8 years and 75% were women. Operative treatment included a posterior approach for 426 patients (99%), with a mean ± SD 12 ± 4 fusion levels. Anterior lumbar interbody fusion was performed in 35 (8%) patients, and 89 (21%) underwent 3-column osteotomy. All PROMs improved significantly from baseline to last follow-up, including scores on ODI (45.4 to 30.5), PCS (31.0 to 38.5), MCS (45.3 to 50.6), SRS-22r total (2.7 to 3.6), SRS-22r activity (2.8 to 3.5), SRS-22r pain (2.3 to 3.4), SRS-22r appearance (2.4 to 3.5), SRS-22r mental (3.4 to 3.7), SRS-22r satisfaction (2.7 to 4.1), NRS for back pain (7.1 to 3.8), and NRS for leg pain (4.8 to 3.0) (all p < 0.001). Degradations in some outcome measures were observed between the 2-year and last follow-up evaluations, but the magnitudes of these degradations were modest and arguably not clinically significant. Overall, 277 (65%) patients had at least 1 complication, including 185 (43%) perioperative, 118 (27%) delayed, and 56 (13%) long term. Notably, the 142 patients who did not achieve 3-year follow-up were similar to the study patients in terms of demographic characteristics, deformities, and baseline PROMs and had similar rates and types of complications. CONCLUSIONS This prospective multicenter analysis demonstrated that operative ASD treatment provided significant improvement of health-related quality of life at minimum 3-year follow-up (mean 4.1 years), suggesting that the benefits of surgery for ASD remain durable at longer follow-up. These findings should prove useful for counseling, cost-effectiveness assessments, and efforts to improve the safety of care.
Collapse
Affiliation(s)
- Elias Elias
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Shay Bess
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Breton Line
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter G Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Zeina Nasser
- 7Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | | | - Khal Kebaish
- 9Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Alan H Daniels
- 11Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | | | - Richard Hostin
- 12Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - Alex Soroceanu
- 13Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 14Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael P Kelly
- 15Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Munish Gupta
- 16Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 19Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 20Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
21
|
Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies. Spine (Phila Pa 1976) 2022; 47:1337-1350. [PMID: 36094109 DOI: 10.1097/brs.0000000000004435] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Literature review. OBJECTIVE The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes. SUMMARY OF BACKGROUND DATA There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure. METHODS A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed. RESULTS Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures. CONCLUSION By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.
Collapse
|
22
|
Koffie RM, de Andrada Pereira B, Lehrman JN, Godzik J, Sawa AGU, Gandhi SV, Kelly BP, Uribe JS, Turner JD. Influence of Spinal Deformity Construct Design on Adjacent-Segment Biomechanics. World Neurosurg 2022; 166:e656-e663. [PMID: 35872128 DOI: 10.1016/j.wneu.2022.07.076] [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: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Adjacent level degeneration is a precursor to construct failure in adult spinal deformity surgery, but whether construct design affects adjacent level degeneration risk remains unclear. Here we present a biomechanical profile of common deformity correction constructs and assess adjacent level biomechanics. METHODS Standard nondestructive flexibility tests (7.5 Nm) were performed on 21 cadaveric specimens: 14 pedicle subtraction osteotomies (PSOs) and 7 anterior column realignment (ACR) constructs. The ranges of motion (ROM) at the adjacent free level in flexion, extension, axial rotation, and lateral bending were measured and analyzed. RESULTS ACR constructs had a lower ROM change on flexion at the proximal adjacent free level than constructs with PSO (1.02 vs. 1.32, normalized to the intact specimen, P < 0.01). Lateral lumbar interbody fusion adjacent to PSO and 4 rods limits ROM at the free level more effectively than transforaminal interbody fusion and 2 rods in correction constructs with PSO. Use of 2 screws to anchor the ACR interbody further decreased ROM at the proximal adjacent free level on flexion, but adding 4 rods in this setting added no further limitation to adjacent segment motion. CONCLUSIONS ACR constructs have less ROM change at the adjacent level compared to PSO constructs. Among constructs with ACR, anchoring the ACR interbody with 2 screws reduces motion at the proximal adjacent free level. When PSOs are used, lateral lumbar interbody fusion adjacent to the PSO level has a greater reduction in adjacent-segment motion than transforaminal interbody fusion, suggesting that deformity construct configuration influences proximal adjacent-segment biomechanics.
Collapse
Affiliation(s)
- Robert M Koffie
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Bernardo de Andrada Pereira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jennifer N Lehrman
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anna G U Sawa
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Shashank V Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Brian P Kelly
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
| |
Collapse
|
23
|
Nevzati E, Moser M, Dietz N, Yaszay B, Lenke LG, Farshad M, Arvind V, Cho SK, Spiessberger A. Clinically relevant biomechanical properties of three different fixation techniques of the upper instrumented vertebra in deformity surgery. Spine Deform 2022; 10:1017-1027. [PMID: 35428950 DOI: 10.1007/s43390-022-00506-8] [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: 12/26/2021] [Accepted: 03/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Adjacent segment disease, junctional kyphosis/failure and pseudarthrosis can negatively impact the mid to long-term outcome in spinal deformity surgery. These complications might be influenced by upper instrumented vertebra (UIV) fixation techniques. In this study we analyze key biomechanical properties of three different UIV fixation techniques and define their ideal clinical use based on patient-specific risk profiles using a finite element analysis (FEA) model. METHODS A T9-pelvis posterior instrumented spinal fusion was assumed. Three different FEA models were created based on the UIV fixation technique: T9 pedicle screws (PS); T9 cortical bone screws (CBS); T9 transverse process hooks (TPH). The three FEA models consisted of T8-T10 bone and ligamentous anatomy derived from a CT scan of a healthy patient as well as spinal implants consisting of either pedicle screws, cortical bone screws or transverse process hooks as well as cobalt chromium rods. The FEA models were constrained at T10, axial load as assumed for a healthy 80 kg male during flexion, extension and lateral bending were applied. As surrogate markers for risk of proximal junctional kyphosis, proximal junctional failure, adjacent segment disease and pseudarthrosis the following biomechanical parameters were calculated: UIV range of motion (ROM); intradiscal stress at UIV/UIV + 1; UIV intravertebral stress and screw pull out forces. One-way ANOVA analyses have been performed to compare biomechanical outcome parameters between the three construct variants under investigation. RESULTS UIV-ROM was restricted during flexion/extension/lateral bending by: PS: 73%/80%/86%, CBS: 71%/81%/85% and TPH: 62%/76%/85%. Average intradiscal stress at UIV/UIV + 1 during flexion/extension/lateral bending was (Mega Pascal, MPa): PS 0.42/0.44/0.38, CBS 0.49/0.4/0.44, TPH 0.66/0.51/0.58; average intravertebral stress of the UIV superior endplate during flexion/extension/lateral bending was (MPa): PS 2.23/2.12/2.21, CBS 1.87/1.98/1.8, TPH 1.67/0.98/1.53. Screw pull-out forces (N) at UIV during flexion/extension/lateral bending were: PS 476/320/375, CBS 444/245/308. Statistically significant differences were found for intradiscal stress as well as vertebral body average stress (p = 0.02 and p = 0.02). CONCLUSION Different UIV fixation techniques carry different biomechanical properties. Pedicle screw fixation is the most rigid, leading to the highest UIV stress and UIV screw pull out forces. Cortical bones screw fixation is similarly rigid; however, UIV stress and UIV screw pull out is significantly lower. Transverse process hook fixation is the least rigid, with the lowest UIV stress, however highest intradiscal stress at UIV/UIV + 1. Thus, these biomechanical differences may help select optimal UIV fixation techniques according to patient specific risk factors.
Collapse
Affiliation(s)
- Edin Nevzati
- Department of Neurosurgery, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Manuel Moser
- Department of Neurosurgery, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Nick Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Burt Yaszay
- Department of Orthopedic Surgery, Rady's Children Hospital San Diego, San Diego, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, New York, USA
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Varun Arvind
- Department of Orthopedic Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York, USA
| | - Samuel K Cho
- Department of Orthopedic Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York, USA
| | - Alexander Spiessberger
- Department of Neurosurgery, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA.
| |
Collapse
|
24
|
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.
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Evolution of Proximal Junctional Kyphosis and Proximal Junctional Failure Rates Over 10 Years of Enrollment in a Prospective Multicenter Adult Spinal Deformity Database. Spine (Phila Pa 1976) 2022; 47:922-930. [PMID: 35472089 DOI: 10.1097/brs.0000000000004364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the evolution of proximal junctional kyphosis (PJK) rate over 10-year enrollment period within a prospective database. SUMMARY OF BACKGROUND DATA PJK is a common complication following adult spinal deformity (ASD) surgery and has been intensively studied over the last decade. METHODS Patients with instrumentation extended to the pelvis and minimum 2-year follow-up were included. To investigate evolution of PJK/proximal junctional failure (PJF) rate, a moving average of 321 patients was calculated across the enrollment period. Logistic regression was used to investigate the association between the date of surgery (DOS) and PJK and/or PJF. Comparison of PJK/PJF rates, demographics, and surgical strategies was performed between the first and second half of the cohort. RESULTS A total of 641 patients met inclusion criteria (age: 64±10 years, 78.2% female, body mass index: 28.3±5.7). The overall rate of radiographic PJK at 2 years was 47.9%; 12.9% of the patients developed PJF, with 31.3% being revised within 2-year follow-up. Stratification by DOS produced two halves. Between these two periods, rate of PJK and PJF demonstrated nonsignificant decrease (50.3%-45.5%, P =0.22) and (15.0%-10.9%, P =0.12), respectively. Linear interpolation suggested a decrease of 1.2% PJK per year and 1.0% for PJF. Patients enrolled later in the study were older and more likely to be classified as pure sagittal deformity ( P <0.001). There was a significant reduction in the use of three-column osteotomies ( P <0.001), an increase in anterior longitudinal ligament release ( P <0.001), and an increase in the use of PJK prophylaxis (31.3% vs 55.1%). Logistical regression demonstrated no significant association between DOS and radiographic PJK ( P =0.19) or PJF ( P =0.39). CONCLUSION Despite extensive research examining risk factors for PJK/PJF and increasing utilization of intraoperative PJK prophylaxis techniques, the rate of radiographic PJK and/or PJF did not significantly decrease across the 10-year enrollment period of this ASD database.
Collapse
|
27
|
Yagi M, Suzuki S, Okada E, Nori S, Tsuji O, Nagoshi N, Nakamura M, Matsumoto M, Watanabe K. Sublaminar Tethers Significantly Reduce the Risk of Proximal Junctional Failure in Surgery for Severe Adult Spinal Deformity: A Propensity Score-matched Analysis. Clin Spine Surg 2022; 35:E496-E503. [PMID: 35034048 DOI: 10.1097/bsd.0000000000001294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/05/2021] [Indexed: 12/12/2022]
Abstract
STUDY DESIGN This was a retrospective case series of prospectively collected data. OBJECTIVE The present study first described the effect of sublaminar tethering (SLT) on proximal junctional failure (PJF) in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA PJF is a devastating complication following ASD surgery. Teriparatide administration and spinous process tethering have been reported as alternatives for the prevention of PJF, but a clinically effective prevention strategy is still a matter of debate. MATERIALS AND METHODS We used data from an ASD database that included 381 patients with ASD (minimum 2-y follow-up). Among them, the data of patients who had a severe sagittal deformity and had surgery from the lower thoracic spine (T9-T11) to the pelvis were extracted and propensity score matched by age, sex, body mass index, bone mineral density, curve type, sagittal alignment, and fused level to clarify whether SLT prevented the development of PJF [SLT vs. control (CTR); age: 67±7 vs. 66±8 y, T-score: -1.4±0.7 vs. -1.3±0.6, body mass index: 22±4 vs. 22±5 kg/m2, C7 sagittal vertical axis (C7SVA): 12±7 vs. 11±5 cm, pelvic incidence-lumbar lordosis (PI-LL): 51±22 vs. 49±21 degrees, pelvic tilt (PT): 36±10 vs. 34±10 degrees, level fused: 11±2 vs. 11±2]. Sixty-four patients were matched into 32 pairs and compared in terms of the postoperative alignment and frequency of PJF. RESULTS Two years postoperatively, C7SVA and PT were significantly larger in the CTR group, while no significant difference in PI-LL was found (C7SVA: 3±3 vs. 6±4 cm, P<0.01, PT: 16±6 vs. 24±9 degrees, P<0.01, PI-LL: 7±9 vs. 11±11 degrees, P=0.22). The proximal junctional angle was significantly greater in the CTR group (proximal junctional kyphosis: 8±8 vs. 17±13 degrees, P<0.01). The incidence of PJF was significantly lower in the SLT group (3% vs. 25%, P=0.03), with an odds ratio of 0.1 (95% confidence interval: 0.0-0.8, P=0.03). CONCLUSION In the propensity score-matched cohort, the incidence of PJF was significantly lower in the SLT group. SLT is a promising procedure that may reduce the risk of PJF in severe ASD surgery.
Collapse
Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine
- Keio Spine Research Group, Tokyo, Japan
| |
Collapse
|
28
|
Zhao G, Wang X, Liu D, Wu K, Zhao J, Fei W. A biomechanical study of ligament tethers strengthening for the prevention of proximal junctional kyphosis after posterior long-segment spinal fusion. Clin Biomech (Bristol, Avon) 2022; 94:105621. [PMID: 35299117 DOI: 10.1016/j.clinbiomech.2022.105621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proximal junctional kyphosis is a known complication of posterior long-segment thoracolumbar fusion. Here, the biomechanical effectiveness of ligament tethers strengthening and vertebral body augmentation, in proximal junctional kyphosis prevention was explored using the finite element analysis. METHODS Based on a validated model of T1-L5 with the pedicle screw system instrumented T8-L5, strengthening models with different strategies were created to assess the range of motion in proximal vertebrae, vertebrae stress, pedicle screw stress, and pressure on intervertebral discs during extension, flexion, lateral bending, and axial rotation motions. Strengthening strategies included two- and three-level posterior ligament tethers (TE-T7-T9 and TE-T6-T9), and tethers with T7 &T8 vertebral body augmentation (TECE-T7-T9 and TECE-T6-T9). FINDINGS Compared to the spinal fusion model, the ligament tethers strengthening significantly reduced the flexion-extension range of motion difference among the proximal vertebrae. During the flexion-extension motion, the T8 vertebra stresses in the TE-T7-T9, TE-T6-T9, TECE-T7-T9, and TECE-T6-T9 models were distinctively reduced, the values decreased by 26.8%, 28.3%, 28.8%, and 9.6%, respectively, during flexion, and by 21.9%, 35.2%, 23%, and 18.6%, respectively, during extension. In the strengthening models, the maximum stresses on the T7/T8 intervertebral disc in the TE-T6-T9 model were reduced by 13.8% during flexion and by 14.7% during extension. INTERPRETATION Based on our results, the ligament strengthening configuration of the three-level posterior tethers produced a more gradual transition in range of motion, vertebrae stresses, and intervertebral discs stress between the fused and non-fused segments, especially during flexion-extension, which may significantly decrease the proximal junctional kyphosis biomechanical risk.
Collapse
Affiliation(s)
- Gaiping Zhao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
| | - Xiaoyu Wang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Dongqing Liu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Kunneng Wu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Jian Zhao
- Department of Orthopedics, Western Theater General Hospital, Chengdu, China
| | - Wang Fei
- Chang-Hai Hospital, The Second Military Medical University, Shanghai, China
| |
Collapse
|
29
|
Du X, Jiang G, Zhu Y, Luo W, Ou Y. A predictive scoring system for proximal junctional kyphosis after posterior internal fixation in elderly patients with chronic osteoporotic vertebral fracture: A single-center diagnostic study. Front Endocrinol (Lausanne) 2022; 13:923778. [PMID: 35937792 PMCID: PMC9354091 DOI: 10.3389/fendo.2022.923778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To establish a predictive scoring system for proximal junctional kyphosis (PJK) after posterior internal fixation in elderly patients with chronic osteoporotic vertebral fracture (COVF). MATERIALS AND METHODS The medical records of 88 patients who were diagnosed with COVF and underwent posterior internal fixation in our hospital from January 2013 to December 2017 were retrospectively analyzed. The included patients were divided into two groups according to whether they suffered PJK after surgery, namely, the PJK group (25 cases) and non-PJK group (63 cases). The following clinical characteristics were recorded and analyzed: age, gender, body mass index (BMI), bone mineral density (BMD), smoking history, fracture segment, proximal junction angle, sagittal vertebral axis, pelvic incidence (PI)-lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), posterior ligamentous complex (PLC) injury, upper instrumented vertebra, lower instrumented vertebra, and the number of fixed segments. The prevalence of these clinical characteristics in the PJK group was evaluated, and the scoring system was established using logistic regression analysis. The performance of the scoring system was also prospectively validated. RESULTS The predictive scoring system was established based on five clinical characteristics confirmed as significant predictors of PJK, namely, age > 70 years, BMI > 28 kg/m2, BMD < -3.5 SD, preoperative PI-LL > 20°, and PLC injury. PJK showed a significantly higher score than non-PJK (7.80 points vs. 2.83 points, t=9.556, P<0.001), and the optimal cutoff value for the scoring system was 5 points. The sensitivity and specificity of the scoring system for predicting postoperative PJK were 80.00% and 88.89%, respectively, in the derivation set and 75.00% and 80.00% in the validation set. CONCLUSION The predictive scoring system was confirmed with satisfactory sensitivity and specificity in predicting PJK after posterior internal fixation in elderly COVF patients. The risk of postoperative PJK in patients with a score of 6-11 is high, while the score of 0-5 is low.
Collapse
Affiliation(s)
- Xing Du
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Guanyin Jiang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Yong Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Wei Luo
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Yunsheng Ou
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
- *Correspondence: Yunsheng Ou,
| |
Collapse
|
30
|
Safaee MM, Haddad AF, Fury M, Maloney PR, Scheer JK, Lau D, Deviren V, Ames CP. Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up. J Neurosurg Spine 2021; 35:752-760. [PMID: 34416735 DOI: 10.3171/2021.2.spine201987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized complications of long-segment spinal fusion. Previous studies have suggested that ligament augmentation can decrease rates of PJF by reducing junctional stress and strengthening upper instrumented vertebrae (UIVs) and adjacent segments. However, there is a paucity of long-term data on the efficacy of ligament augmentation in preventing PJF. In this study, the authors sought to determine the effect of ligament augmentation on rates of PJF in a cohort of adult spinal deformity patients with at least 1 year of follow-up. METHODS They conducted a retrospective analysis of ligament augmentation in a consecutive series of surgical patients with adult spinal deformity. Data on patient demographics, surgical characteristics, and surgery for PJF were collected. The minimum follow-up was 12 months. Univariate and multivariate analyses were performed to identify factors associated with reoperation for PJF. RESULTS The authors identified a total of 242 patients (166 women [68.6%]) with ligament augmentation whose mean age was 66 years. The mean number of fused levels was 10, with a UIV distribution as follows: 90 upper thoracic UIVs (37.2%) and 152 lower thoracic UIVs (62.8%). Compared to a historical cohort of 77 patients treated before implementation of ligament augmentation, reoperation for PJF was significantly lower with ligament augmentation (15.6% vs 3.3%, p < 0.001). In a multivariate model, only ligament augmentation (OR 0.184, 95% CI 0.071-0.478, p = 0.001) and number of fused levels (OR 0.762, 95% CI 0.620-0.937, p = 0.010) were associated with reductions in reoperation for PJF. CONCLUSIONS Ligament augmentation was associated with significant reductions in the rate of reoperation for PJF at 12 months in a cohort of adult spinal deformity patients. The most dramatic reduction was seen among patients with lower thoracic UIV. These data suggest that in appropriately selected patients, ligament augmentation may be a valuable adjunct for PJF reduction; however, long-term follow-up is needed.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Vedat Deviren
- 2Orthopedic Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- Departments of1Neurological Surgery and
- 2Orthopedic Surgery, University of California, San Francisco, California
| |
Collapse
|
31
|
Strong MJ, Yee TJ, Muhlestein WE, Saadeh YS, Park P. Commentary: 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:E469-E470. [PMID: 34560781 DOI: 10.1093/ons/opab363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Strong
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Yamaan S Saadeh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
32
|
Yamamoto S, Malakoutian M, Theret M, Street J, Rossi F, Brown SHM, Saito M, Oxland TR. The Effect of Posterior Lumbar Spinal Surgery on Biomechanical Properties of Rat Paraspinal Muscles 13 Weeks After Surgery. Spine (Phila Pa 1976) 2021; 46:E1125-E1135. [PMID: 34156788 DOI: 10.1097/brs.0000000000004036] [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 Preclinical study in rodents. OBJECTIVE To investigate changes in biomechanical properties of paraspinal muscles following a posterior spinal surgery in an animal model. SUMMARY OF BACKGROUND DATA Posterior spine surgery damages paraspinal musculature per histological and imaging studies. The biomechanical effects of these changes are unknown. METHODS 12 Sprague-Dawley rats were divided equally into sham and surgical injury (SI) groups. For sham, the skin and lumbodorsal fascia were incised at midline. For SI, the paraspinal muscles were detached from the vertebrae, per normal procedure. Thirteen weeks postsurgery, multifidus and longissimus biopsies at L1, L3, and L5 levels were harvested on the right. From each biopsy, three fibers and three to six bundles of fibers (∼10-20 fibers ensheathed in their extracellular matrix) were tested mechanically to measure their passive elastic modulus. The collagen content and fatty infiltration of each biopsy were also examined histologically by immunofluorescence staining. Nonparametric statistical methods were used with a 1.25% level of significance. RESULTS A total of 220 fibers and 279 bundles of fibers were tested. The elastic moduli of the multifidus and longissimus fibers and longissimus fiber bundles were not significantly different between the SI and sham groups. However, the elastic modulus of multifidus fiber bundles was significantly greater in the SI group compared to sham (SI median 82 kPa, range 23-284; sham median 38 kPa, range 23-50, P = 0.0004). The elastic modulus of multifidus fiber bundles in the SI group was not statistically different between spinal levels (P = 0.023). For histology, only collagen I deposition in multifidus was significantly greater in the SI group (median 20.8% vs. 5.8% for sham, P < 0.0001). CONCLUSION The surgical injury increased the passive stiffness of the multifidus fiber bundles. Increased collagen content in the extracellular matrix is the likely reason and these changes may be important in the postoperative compensation of the spine.Level of Evidence: N/A.
Collapse
Affiliation(s)
- Shun Yamamoto
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Masoud Malakoutian
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Mechanical Engineering, The University of British Columbia, Vancouver, Canada
| | - Marine Theret
- School of Biomedical Engineering, The University of British Columbia, Vancouver, Canada
- Department of Medical Genetics, The University of British Columbia, Vancouver, Canada
| | - John Street
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
| | - Fabio Rossi
- School of Biomedical Engineering, The University of British Columbia, Vancouver, Canada
- Department of Medical Genetics, The University of British Columbia, Vancouver, Canada
| | - Stephen H M Brown
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Thomas R Oxland
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Mechanical Engineering, The University of British Columbia, Vancouver, Canada
| |
Collapse
|
33
|
Rodnoi P, Le H, Hiatt L, Wick J, Barber J, Javidan Y, Roberto R, Klineberg EO. Ligament Augmentation With Mersilene Tape Reduces the Rates of Proximal Junctional Kyphosis and Failure in Adult Spinal Deformity. Neurospine 2021; 18:580-586. [PMID: 34610689 PMCID: PMC8497241 DOI: 10.14245/ns.2142420.210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate prevention of proximal junctional kyphosis (PJK) and failure (PJF) following adult spinal deformity (ASD) surgery utilizing a novel technique of posterior ligament augmentation with polyester fiber tether. METHODS This study evaluated ASD adult patients who underwent posterior decompression and instrumented fusion from the thoracolumbar junction (T9-L1) to the pelvis from 2011-2017. Basic demographic data were obtained. Radiographic outcomes included proximal junctional angle (PJA), sagittal vertical axis, PJK, and PJF. The study population was divided into patients who had ASD surgery with and without ligamentous augmentation. RESULTS A total of 43 subjects were evaluated, including 20 without and 23 with ligamentous augmentation. PJA increased over time for both groups. PJA was smaller for the augmented group, and rate of increase in PJA was slower in the augmented group (p < 0.0001). The rate of PJK was significantly higher in the nonaugmented group (p = 0.01). PJF was significantly less common in the augmented group (p = 0.003). Time to revision surgery was lower in the nonaugmented group (p = 0.003). CONCLUSION Our novel ligament augmentation technique utilizing polyethylene tape is an effective technique to slow progression of the PJA and lower the risk for proximal junctional disease in ASD surgery.
Collapse
Affiliation(s)
- Pope Rodnoi
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Hai Le
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Luke Hiatt
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Joseph Wick
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Joshua Barber
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Yashar Javidan
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Rolando Roberto
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| |
Collapse
|
34
|
Nanostructural interface and strength of polymer composite scaffolds applied to intervertebral bone. Colloids Surf A Physicochem Eng Asp 2021. [DOI: 10.1016/j.colsurfa.2021.127190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
Tempel ZJ, Hlubek RJ, Kachmann MC, Body A, Okonkwo DO, Kanter AS, Buchholz AL, Krueger BM. Novel Distributed Loading Technique Using Multimaterial, Long-Segment Spinal Constructs to Prevent Proximal Junctional Pathology in Adult Spinal Deformity Correction-Operative Technique and Radiographic Findings. World Neurosurg 2021; 155:e264-e270. [PMID: 34418605 DOI: 10.1016/j.wneu.2021.08.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) and proximal junction failure are common and costly complications after long-segment adult spinal deformity (ASD) correction. Although much research has focused on the concept of "softening the landing" to prevent proximal junction pathologies, long-segment constructs largely deviate from the force-deformation curve of the physiologic spine. Our novel distributed loading technique for ASD correction is described using multimaterial, long-segment constructs to create a biomechanically sound, yet physiologic, decremental stiffness toward the rostral end. METHODS Operative steps detail the custom-designed constructs of dual-headed pedicle screws and varied rod diameters and materials (cobalt chromium or titanium) for an initial 20 patients (mean 66.6 ± 4.8 years). Standing scoliosis films were obtained preoperatively and at regular intervals postoperatively to assess for PJK. RESULTS No patient had evidence of PJK or proximal junction failure at latest radiographic follow-up (mean 17.9 months, range 13-25 months). Radiographic findings for sagittal vertical axis averaged 11.2 ± 5.6 cm preoperatively and 3.6 ± 2.3 cm postoperatively. Compared with preoperative parameters, postoperative reductions in pelvic incidence-lumbar lordosis mismatch averaged 28.7 ± 12.9 degrees, and sagittal vertical axis averaged 7.6 ± 5.2 cm while PJA was essentially unchanged. CONCLUSIONS Preliminary results suggest that the distributed loading technique is promising for prevention of PJK with stiffness gradients that mimic the force-deformation curve of the physiologic posterior tension band. Our technique may optimize the degree of stress at the proximal junction without overwhelming the anterior column bony while remodeling and mature arthrodesis takes place.
Collapse
Affiliation(s)
| | | | | | - Alaina Body
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | |
Collapse
|
37
|
Zhao G, Wu K, Liu D, Zhao J, Liang P, Hang S. A biomechanical study of proximal junctional kyphosis after posterior long segment fusion with vertebral body augmentation. Clin Biomech (Bristol, Avon) 2021; 87:105415. [PMID: 34174675 DOI: 10.1016/j.clinbiomech.2021.105415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/19/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023]
Abstract
Background Proximal junction kyphosis is a common clinical complication of posterior long-segment spinal fusion and vertebral body augmentation method is one of the effective approaches to prevent it. The purpose of this study was to explore the biomechanical effect of proximal junction kyphosis after posterior long-segment thoracolumbar fusion with different vertebral augmentation schemes using finite element analysis. Methods 3D nonlinear finite element models of T1-L5 spine posterior long-segment T8-L5 thoracolumbar fusion combined with T7, T8 and T7&T8 vertebral bone cement augmentation were constructed from human spine CT data and clinical surgical operation scheme to analyze the von Mises stress in the vertebrae, intervertebral discs pressure and pedicle screws system loads under the flexion, extension, lateral bending and axial rotation motion. Findings Compared with thoracolumbar posterior long-segment fusion model, T7 maximum stress in T7, T8 and T7&T8 vertebrae augmentation models were reduced by 8.64%, 7.17%, 8.51%;0.79%, -3.88%,1.67%;4.02%, 5.30%, 4.27% and 3.18%, 3.06%, -6.38% under the flexion, extension, lateral bending and axial rotation motion. T7/T8 intervertebral disc pressure in T7, T8, T7&T8 vertebral augmentation models were 36.71Mpa,29.78Mpa,36.47Mpa;22.25Mpa,18.35Mpa,22.06Mpa;84.27Mpa,68.17Mpa, 83.89Mpa and 52.23Mpa, 38.78Mpa,52.10Mpa under the same condition. The maximum stress 178.2Mpa of pedicle screws is mainly distributed at the root of screw. Interpretation Thoracolumbar posterior long-segment fusion with proximal double-segment vertebral augmentation should be recommended to prevent proximal junction kyphosis than single-segment augmentation. Simulation results can provide theoretical foundations and assist surgeons in selecting the appropriate operation scheme.
Collapse
Affiliation(s)
- Gaiping Zhao
- Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China.
| | - Kunneng Wu
- Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Dongqing Liu
- Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Jian Zhao
- Department of Orthopedics, Western Theater General Hospital, Chengdu, China
| | - Peng Liang
- Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shengqi Hang
- Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| |
Collapse
|
38
|
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.
Collapse
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.
| |
Collapse
|
39
|
Passias PG, Alas H, Naessig S, Kim HJ, Lafage R, Ames C, Klineberg E, Pierce K, Ahmad W, Burton D, Diebo B, Bess S, Hamilton DK, Gupta M, Park P, Line B, Shaffrey CI, Smith JS, Schwab F, Lafage V. Timing of conversion to cervical malalignment and proximal junctional kyphosis following surgical correction of adult spinal deformity: a 3-year radiographic analysis. J Neurosurg Spine 2021; 34:830-838. [PMID: 33740768 DOI: 10.3171/2020.8.spine20320] [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: 04/07/2020] [Accepted: 08/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the conversion rate from baseline cervical alignment to postoperative cervical deformity (CD) and the corresponding proximal junctional kyphosis (PJK) rate in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery. METHODS The operative records of patients with ASD with complete radiographic data beginning at baseline up to 3 years were included. Patients with no baseline CD were postoperatively stratified by Ames CD criteria (T1 slope-cervical lordosis mismatch [TS-CL] > 20°, cervical sagittal vertical axis [cSVA] > 40 mm), where CD was defined as fulfilling one or more of the Ames criteria. Severe CD was defined as TS-CL > 30° or cSVA > 60 mm. Follow-up intervals were established after ASD surgery, with 6 weeks postoperatively defined as early; 6 weeks-1 year as intermediate; 1-2 years as late; and 2-3 years as long-term. Descriptive analyses and McNemar tests identified the CD conversion rate, PJK rate (< -10° change in uppermost instrumented vertebra and the superior endplate of the vertebra 2 levels superior to the uppermost instrumented vertebra), and specific alignment parameters that converted. RESULTS Two hundred sixty-six patients who underwent ASD surgery (mean age 59.7 years, 77.4% female) met the inclusion criteria; 103 of these converted postoperatively, and the remaining 163 did not meet conversion criteria. Thirty-eight patients converted to CD early, 26 converted at the intermediate time point, 29 converted late, and 10 converted in the long-term. At conversion, the early group had the highest mean TS-CL at 25.4° ± 8.5° and the highest mean cSVA at 33.6 mm-both higher than any other conversion group. The long-term group had the highest mean C2-7 angle at 19.7° and the highest rate of PJK compared to other groups (p = 0.180). The early group had the highest rate of conversion to severe CD, with 9 of 38 patients having severe TS-CL and only 1 patient per group converting to severe cSVA. Seven patients progressed from having only malaligned TS-CL at baseline (with normal cSVA) to CD with both malaligned TS-CL and cSVA by 6 weeks. Conversely, only 2 patients progressed from malaligned cSVA to both malaligned cSVA and TS-CL. By 1 year, the former number increased from 7 to 26 patients, and the latter increased from 2 to 20 patients. The revision rate was highest in the intermediate group at 48.0%, versus the early group at 19.2%, late group at 27.3%, and long-term group at 20% (p = 0.128). A higher pelvic incidence-lumbar lordosis mismatch, lower thoracic kyphosis, and a higher thoracic kyphosis apex immediately postoperatively significantly predicted earlier rather than later conversion (all p < 0.05). Baseline lumbar lordosis, pelvic tilt, and sacral slope were not significant predictors. CONCLUSIONS Patients with ASD with normative cervical alignment who converted to CD after thoracolumbar surgery had varying radiographic findings based on timing of conversion. Although the highest number of patients converted within 6 weeks postoperatively, patients who converted in the late or long-term follow-up intervals had higher rates of concurrent PJK and greater radiographic progression.
Collapse
Affiliation(s)
- Peter G Passias
- 1Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York
| | - Haddy Alas
- 1Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York
| | - Sara Naessig
- 1Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York
| | - Han Jo Kim
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Christopher Ames
- 3Department of Neurological Surgery, University of California, San Francisco
| | - Eric Klineberg
- 4Department of Orthopaedic Surgery, University of California, Davis, California
| | - Katherine Pierce
- 1Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York
| | - Waleed Ahmad
- 1Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York
| | - Douglas Burton
- 5Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Bassel Diebo
- 6SUNY Downstate Medical Center/University Hospital Brooklyn, New York, New York
| | - Shay Bess
- 7Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - D Kojo Hamilton
- 8Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Munish Gupta
- 9Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Paul Park
- 10Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Breton Line
- 11Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher I Shaffrey
- 12Department of Neurosurgery and Orthopaedic Surgery, Duke Health, Durham, North Carolina; and
| | - Justin S Smith
- 13Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Frank Schwab
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| |
Collapse
|
40
|
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.
Collapse
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
| |
Collapse
|
41
|
Sardar ZM, Kim Y, Lafage V, Rand F, Lenke L, Klineberg E. State of the art: proximal junctional kyphosis-diagnosis, management and prevention. Spine Deform 2021; 9:635-644. [PMID: 33452631 DOI: 10.1007/s43390-020-00278-z] [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] [Received: 06/09/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Abstract
Proximal junctional kyphosis (PJK) is a common problem that may occur following the surgical treatment of adult patients with spinal deformity. It is defined as the proximal junctional sagittal angle from the UIV and UVI + 2 of at least 10° AND at least 10° greater than the preop measurement. The reported incidence of radiographic PJK in the literature varies between 17 and 46%. A smaller subset of these patients may need revision surgery and are defined as proximal junctional failure (PJF), which can be associated with vertebral fracture, vertebral subluxation, failure of instrumentation, and neurological deficits. Several risk factors for development of PJK have been proposed. However, large-scale prospective studies are needed to better identify strategies to reduce the incidence of PJK.
Collapse
Affiliation(s)
- Zeeshan M Sardar
- Spine and Scoliosis Surgery, College of Physicians and Surgeons, NewYork-Presbyterian, The Allen Hospital, Columbia University, 5141 Broadway, New York, NY, 3FW, USA.
| | - Yongjung Kim
- Spine and Scoliosis Surgery, College of Physicians and Surgeons, NewYork-Presbyterian, The Allen Hospital, Columbia University, 5141 Broadway, New York, NY, 3FW, USA
| | | | - Frank Rand
- New England Baptist Hospital, Boston, MA, USA
| | - Lawrence Lenke
- Spine and Scoliosis Surgery, College of Physicians and Surgeons, NewYork-Presbyterian, The Allen Hospital, Columbia University, 5141 Broadway, New York, NY, 3FW, USA
| | | | | |
Collapse
|
42
|
Doodkorte RJP, Roth AK, Arts JJ, Lataster LMA, van Rhijn LW, Willems PC. Biomechanical comparison of semirigid junctional fixation techniques to prevent proximal junctional failure after thoracolumbar adult spinal deformity correction. Spine J 2021; 21:855-864. [PMID: 33493681 DOI: 10.1016/j.spinee.2021.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/08/2021] [Accepted: 01/18/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity patients treated operatively by long-segment instrumented spinal fusion are prone to develop proximal junctional kyphosis (PJK) and failure (PJF). A gradual transition in range of motion (ROM) at the proximal end of spinal instrumentation may reduce the incidence of PJK and PJF, however, previously evaluated techniques have not directly been compared. PURPOSE To determine the biomechanical characteristics of five different posterior spinal instrumentation techniques to achieve semirigid junctional fixation, or "topping-off," between the rigid pedicle screw fixation (PSF) and the proximal uninstrumented spine. STUDY DESIGN Biomechanical cadaveric study. METHODS Seven fresh-frozen human cadaveric spine segments (T8-L3) were subjected to ex vivo pure moment loading in flexion-extension, lateral bending and axial rotation up to 5 Nm. The native condition, three-level PSF (T11-L2), PSF with supplemental transverse process hooks at T10 (TPH), and two sublaminar taping techniques (knotted and clamped) as one- (T10) or two-level (T9, T10) semirigid junctional fixation techniques were compared. The ROM and neutral zone (NZ) of the segments were normalized to the native condition. The linearity of the transition zones over three or four segments was determined through linear regression analysis. RESULTS All techniques achieved a significantly reduced ROM at T10-T11 in flexion-extension and axial rotation relative to the PSF condition. Additionally, both two-level sublaminar taping techniques (CT2, KT2) had a significantly reduced ROM at T9-T10. One-level clamped sublaminar tape (CT1) had a significantly lower ROM and NZ compared with one-level knotted sublaminar tape (KT1) at T10-T11. Linear regression analysis showed the highest linear correlation between ROM and vertebral level for TPH and the lowest linear correlation for CT2. CONCLUSIONS All studied semirigid junctional fixation techniques significantly reduced the ROM at the junctional levels and thus provide a more gradual transition than pedicle screws. TPH achieves the most linear transition over three vertebrae, whereas KT2 achieves that over four vertebrae. In contrast, CT2 effectively is a one-level semirigid junctional fixation technique with a shift in the upper rigid fixation level. Clamped sublaminar tape reduces the NZ greatly, whereas knotted sublaminar tape and TPH maintain a more physiologic NZ. Clinical validation is ultimately required to translate the biomechanics of various semirigid junctional fixation techniques into the clinical goal of reducing the incidence of proximal junctional kyphosis and failure. CLINICAL SIGNIFICANCE The direct biomechanical comparison of multiple instrumentation techniques that aim to reduce the incidence of PJK after thoracolumbar spinal fusion surgery provides a basis upon which clinical studies could be designed. Furthermore, the data provided in this study can be used to further analyze the biomechanical effects of the studied techniques using finite element models to better predict their post-operative effectiveness.
Collapse
Affiliation(s)
- Remco J P Doodkorte
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Alex K Roth
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Jacobus J Arts
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - L M Arno Lataster
- Department of Anatomy and Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Lodewijk W van Rhijn
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Paul C Willems
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| |
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
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.
Collapse
|
45
|
|
46
|
|
47
|
Prost S, Pesenti S, Fuentes S, Tropiano P, Blondel B. Treatment of osteoporotic vertebral fractures. Orthop Traumatol Surg Res 2021; 107:102779. [PMID: 33321233 DOI: 10.1016/j.otsr.2020.102779] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/17/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023]
Abstract
Osteoporosis is a public health problem that is contributing to an increasing number of osteoporotic vertebral fractures. The aim of this lecture is to summarize the current state of knowledge about osteoporotic fractures by answering five questions. 1/How does the spine typically age and how is osteoporosis diagnosed? Various normal aging processes will gradually modify the vertebral column (static, dynamic, bone quality). Osteoporosis is diagnosed through a DEXA scan. 2/How is an osteoporotic fracture evaluated clinically and radiologically? Magnetic resonance imaging is the preferred modality for making the diagnosis and selecting the most appropriate treatment. 3/What are the treatment options for an osteoporotic fracture? The options are conservative treatment, conventional surgery, and minimally invasive techniques (cementoplasty, percutaneous instrumentation). 4/Which fractures should be treated, and which technique should be used? The choice is clear when neurological deficits are present, although the indications are less firm when there is no deficit. The treatment can be conservative (back brace) if the fracture is non-displaced and minimally painful, vertebroplasty if the fracture is painful and shows hyperintensity on T2-STIR sequences, vertebral expansion if the radiological deformity worsens along with symptoms. 5/What are the technical challenges and complications related to the presence of osteoporosis when treating vertebral fractures surgically? The reduced bone stock increases the risk of poor implant hold and postoperative mechanical complications (adjacent fracture, junctional kyphosis). Technical solutions have been developed (augmented screw fixation, transitional zone) to limit their impact. It is essential to know and master these techniques, and their indications. Treatment of the osteoporosis itself is crucial. Level of evidence V; Expert opinion.
Collapse
Affiliation(s)
- Solène Prost
- Unité de chirurgie rachidienne, Aix-Marseille université, AP-HM, CNRS, ISM, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Sébastien Pesenti
- Unité de chirurgie rachidienne, Aix-Marseille université, AP-HM, CNRS, ISM, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Stéphane Fuentes
- Unité de chirurgie rachidienne, Aix-Marseille université, AP-HM, CNRS, ISM, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Patrick Tropiano
- Unité de chirurgie rachidienne, Aix-Marseille université, AP-HM, CNRS, ISM, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Benjamin Blondel
- Unité de chirurgie rachidienne, Aix-Marseille université, AP-HM, CNRS, ISM, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France.
| |
Collapse
|
48
|
Jakinapally S, Yamato Y, Hasegawa T, Togawa D, Yoshida G, Banno T, Arima H, Oe S, Yasuda T, Ushirozako H, Yamada T, Ide K, Watanabe Y, Matsuyama Y. Effect of sagittal shape on proximal junctional kyphosis following thoracopelvic corrective fusion for adult spinal deformity: postoperative inflection vertebra cranial to T12 is a significant risk factor. Spine Deform 2020; 8:1313-1323. [PMID: 32578158 DOI: 10.1007/s43390-020-00162-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 06/16/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective analysis of a prospectively collected consecutive case series of patients with adult spinal deformity (ASD). OBJECTIVE This study aimed to investigate the impact of the geometrical sagittal shape of the corrected spine on the development of proximal junctional kyphosis (PJK). Several studies have documented risk factors for PJK in ASD surgery. Geometrical assessment is vital for evaluating sagittal spinal deformity. It is essential to assess the postoperative geometrical shape of the spine and the location of the correction in the spine to decrease postoperative junctional stress and PJK. METHODS Consecutive patients with ASD who underwent corrective fusion with long constructs to the pelvis were included. Patients with neuromuscular disease, congenital and adolescent scoliosis, infection, and spinal tumor were excluded. We investigated the spinopelvic and geometrical parameters of the whole spine. The locations of the thoracic and lumbar apical vertebrae and the inflection vertebrae (IV), where the curvature of the associated adjacent vertebral bodies changes from kyphosis to lordosis, were investigated. The subjects were divided into PJK included patients who underwent revision surgery for junctional failure or with a change in proximal junctional angle ≥ 20°, and non-PJK groups. RESULTS A total of 139 patients (mean age, 69.6 years; range 18-82 years) were included. There were 47 and 92 patients in the PJK and non-PJK groups, respectively. The IV were located significantly cranial and posterior, the lumbar apex were located significantly posterior in the PJK group at the immediate postoperative time points. The significant risk factors for PJK on binary logistic regression were cranial IV and posterior lumbar apical vertebrae. The incidence of PJK in patients with IV at T12 or cranial tends PJK significantly higher (69%) than at L1 or caudal (26%). CONCLUSIONS Geometrical spinal shape should be taken into account to reduce the rate of postoperative mechanical complications. LEVEL OF EVIDENCE Level of evidence III.
Collapse
Affiliation(s)
- Sreenath Jakinapally
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Yu Yamato
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan.
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-ku, Hamamatsu, Shizuoka, Japan.
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Daisuke Togawa
- Department of Orthopaedic Surgery, Kindai Nara Hospital, 1248-1, Otodacho, Ikoma, Japan
| | - Go Yoshida
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Hideyuki Arima
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Shin Oe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Tatsuya Yasuda
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Koichirou Ide
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Yuh Watanabe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, Japan
| |
Collapse
|
49
|
Smith JS, Buell TJ, Shaffrey CI, Kim HJ, Klineberg E, Protopsaltis T, Passias P, Mundis GM, Eastlack R, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Gupta M, Burton D, Hostin R, Hart R, Lafage V, Lafage R, Schwab FJ, Bess S, Ames CP. Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up. J Neurosurg Spine 2020; 33:588-600. [PMID: 32559746 DOI: 10.3171/2020.4.spine20213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although surgical treatment can provide significant improvement of symptomatic adult cervical spine deformity (ACSD), few reports have focused on the associated complications. The objective of this study was to assess complication rates at a minimum 1-year follow-up based on a prospective multicenter series of ACSD patients treated surgically. METHODS A prospective multicenter database of consecutive operative ACSD patients was reviewed for perioperative (< 30 days), early (30-90 days), and delayed (> 90 days) complications with a minimum 1-year follow-up. Enrollment required at least 1 of the following: cervical kyphosis > 10°, cervical scoliosis > 10°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°. RESULTS Of 167 patients, 133 (80%, mean age 62 years, 62% women) had a minimum 1-year follow-up (mean 1.8 years). The most common diagnoses were degenerative (45%) and iatrogenic (17%) kyphosis. Almost 40% of patients were active or past smokers, 17% had osteoporosis, and 84% had at least 1 comorbidity. The mean baseline Neck Disability Index and modified Japanese Orthopaedic Association scores were 47 and 13.6, respectively. Surgical approaches were anterior-only (18%), posterior-only (47%), and combined (35%). A total of 132 complications were reported (54 minor and 78 major), and 74 (56%) patients had at least 1 complication. The most common complications included dysphagia (11%), distal junctional kyphosis (9%), respiratory failure (6%), deep wound infection (6%), new nerve root motor deficit (5%), and new sensory deficit (5%). A total of 4 deaths occurred that were potentially related to surgery, 2 prior to 1-year follow-up (1 cardiopulmonary and 1 due to obstructive sleep apnea and narcotic use) and 2 beyond 1-year follow-up (both cardiopulmonary and associated with revision procedures). Twenty-six reoperations were performed in 23 (17%) patients, with the most common indications of deep wound infection (n = 8), DJK (n = 7), and neurological deficit (n = 6). Although anterior-only procedures had a trend toward lower overall (42%) and major (21%) complications, rates were not significantly different from posterior-only (57% and 33%, respectively) or combined (61% and 37%, respectively) approaches (p = 0.29 and p = 0.38, respectively). CONCLUSIONS This report provides benchmark rates for ACSD surgery complications at a minimum 1-year (mean 1.8 years) follow-up. The marked health and functional impact of ACSD, the frail population it affects, and the high rates of surgical complications necessitate a careful risk-benefit assessment when contemplating surgery. Collectively, these findings provide benchmarks for complication rates and may prove useful for patient counseling and efforts to improve the safety of care.
Collapse
Affiliation(s)
- Justin S Smith
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I Shaffrey
- Departments of2Neurosurgery and
- 3Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | | | - Peter Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | | | - Vedat Deviren
- 8Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Michael P Kelly
- 9Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
| | - Alan H Daniels
- 10Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 11Department of Orthopedic Surgery, Leatherman Spine Center, Louisville, Kentucky
| | - Alex Soroceanu
- 12Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - Munish Gupta
- 9Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
| | - Doug Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard Hostin
- 14Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Robert Hart
- 15Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Virginie Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank J Schwab
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 16Presbyterian St. Luke's Medical Center, Denver, Colorado; and
| | - Christopher P Ames
- 17Department of Neurological Surgery, University of California, San Francisco, California
| |
Collapse
|
50
|
Surgical Design Optimization of Proximal Junctional Kyphosis. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:8886599. [PMID: 33014322 PMCID: PMC7525290 DOI: 10.1155/2020/8886599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/19/2020] [Accepted: 09/01/2020] [Indexed: 02/05/2023]
Abstract
Purpose The objective of this study was to construct a procedural planning tool to optimize the proximal junction angle (PJA) to prevent postoperative proximal junctional kyphosis (PJK) for each scoliosis patient. Methods Twelve patients (9 patients without PJK and 3 patients with PJK) who have been followed up for at least 2 years after surgery were included. After calculating the loading force on the cephalad intervertebral disc of upper instrumented vertebra of each patient, the finite-element method (FEM) was performed to calculate the stress of each element. The stress information was summarized into the difference value before and after operation in different regions of interest. A two-layer fully connected neural network method was applied to model the relationship between the stress information and the risk of PJK. Leave-one-out cross-validation and sensitivity analysis were implemented to assess the accuracy and stability of the trained model. The optimal PJA was predicted based on the learned model by optimization algorithm. Results The mean prediction accuracy was 83.3% for all these cases, and the area under the curve (AUC) of prediction was 0.889. And the output variance of this model was less than 5% when the important factor values were perturbed in a range of 5%. Conclusion Our approach integrated biomechanics and machine learning to support the surgical decision. For a new individual, the risk of PJK and optimal PJA can be simultaneously predicted based on the learned model.
Collapse
|