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Linzey JR, Lillard J, LaBagnara M, Park P. Complications and Avoidance in Adult Spinal Deformity Surgery. Neurosurg Clin N Am 2023; 34:665-675. [PMID: 37718113 DOI: 10.1016/j.nec.2023.06.012] [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] [Indexed: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is a complex disease that can result in significant disability. Although surgical treatment has been shown to be of benefit, the complication rate in the perioperative and postoperative periods can be as high as 70%. Some of the most common complications of ASD surgery include intraoperative cerebrospinal fluid leak, high blood loss, new neurologic deficit, hardware failure, proximal junctional kyphosis/failure, pseudarthrosis, surgical site infection, and medical complications. For each of these complications, one or more strategies can be utilized to avoid and/or minimize the consequences.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jock Lillard
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Michael LaBagnara
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Paul Park
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA.
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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.
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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.
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Affiliation(s)
| | | | | | | | - Kirill V Nourski
- Departments of1Neurosurgery and.,3Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa
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Hirase T, Shin C, Ling J, Phelps B, Haghshenas V, Saifi C, Hanson DS. S2 alar-iliac screw versus traditional iliac screw for spinopelvic fixation: a systematic review of comparative biomechanical studies. Spine Deform 2022; 10:1279-1288. [PMID: 35763199 DOI: 10.1007/s43390-022-00528-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To review and compare biomechanical properties between S2 alar-iliac (S2AI) screws and traditional iliac screws for spinopelvic fixation. METHODS A systematic review was performed according to PRISMA guidelines. All clinical, cadaveric, and finite-element model (FEM) studies that compared the biomechanical properties between S2AI screws and traditional iliac screws were included. Study methodological quality for cadaveric studies were analyzed using the Quality Appraisal for Cadaveric Studies (QUACS) scale. RESULTS Eight studies (4 cadaveric, 4 FEM) analyzing 58 S2AI screws and 48 traditional iliac screws were included. According to QUACS, the overall methodological quality was "moderate to good" for all four cadaveric studies. All four cadaveric studies found no difference in biomechanical stiffness, screw toggle, rod strain, and/or load-to-failure between the S2AI screws and traditional iliac screws for spinopelvic fixation. All four FEM studies found that S2AI screws were associated with lower implant stresses compared to traditional iliac screws. CONCLUSIONS There is moderate biomechanical evidence to suggest that there is no significant difference in stability and stiffness between S2AI screws and traditional iliac screws for spinopelvic fixation. However, there is some evidence to support that the placement of S2AI screws may have lower implant stresses on the overall lumbosacral instrumentation compared to traditional iliac screws.
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Affiliation(s)
- Takashi Hirase
- Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX, 77030, USA.
- Texas A&M University Health Science Center College of Medicine, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
| | - Caleb Shin
- Texas A&M University Health Science Center College of Medicine, 8447 Riverside Pkwy, Bryan, TX, 77807, USA
| | - Jeremiah Ling
- Texas A&M University Health Science Center College of Medicine, 8447 Riverside Pkwy, Bryan, TX, 77807, USA
| | - Brian Phelps
- Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX, 77030, USA
| | - Varan Haghshenas
- Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX, 77030, USA
| | - Comron Saifi
- Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX, 77030, USA
| | - Darrell S Hanson
- Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX, 77030, USA
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Tanaka M, Mehta R, Yamauchi T, Arataki S, Fujiwara Y, Shinohara K, Yamane K. Triangular fixation to prevent proximal screw pullout for adult spinal deformity Surgery: A technical note. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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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.
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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
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Liao JC, Chen WJ, Wu SCH. Proximal junctional fractures after long-segment instrumented fusion: comparisons between upper instrumented vertebrae and upper instrumented vertebrae + 1. J Orthop Surg Res 2022; 17:271. [PMID: 35568929 PMCID: PMC9107646 DOI: 10.1186/s13018-022-03173-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Proximal junctional failure (PJF) is a well-known complication after long-segment (at least 4 vertebral levels) instrumented fusion. The etiologies of PJF include degenerative processes or are fracture induced. The fracture type of PJF includes vertebral fractures developed at the upper instrumented vertebrae (UIV) or UIV + 1. The purpose of this study was to investigate clinical and radiographic features of these two subtypes of PJF and to analyze risk factors in these patients.
Method In total, forty-two patients with PJF who underwent revision surgery were included. Twenty patients suffered fractures at the UIV, and the other 22 cases had fractures at UIV + 1. The weighted Charlson Comorbidity Index (CCI) and bone mineral density (BMD) T scores for these patients were recorded. Surgery-related data of index surgery and complications were collected. Radiographic parameters including pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), lumbar lordosis (LL), and PI-LL were recorded in both groups before and after the revision surgery.
Result Both groups had severe osteoporosis and comorbidities. The interval between the index surgery and revision surgery was shorter in the UIV group than in the UIV + 1 group (8.2 months vs. 35.9 months; p < 0.001). The analysis for radiographic parameters in UIV and UIV + 1 group demonstrated no significant change before and after the revision surgery. However, the preoperative radiographic analysis showed a larger PT (31.5° vs. 23.2°, p = 0.013), PI (53.7° vs. 45.3°, p = 0.035), and SVA (78.6° vs. 59.4°, p = 0.024) in the UIV group compared to the UIV + 1 group. The postoperative radiographic analysis showed a larger PI-LL (27.8° vs. 18.1°, p = 0.016) in the UIV group compared to the UIV + 1 group. Conclusion PJF in the UIV group tends to occur earlier than in the UIV + 1 group. Moreover, more severe global sagittal imbalances were found in the UIV group than in UIV + 1 group.
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Affiliation(s)
- Jen-Chung Liao
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fu-Shin Street Kweishian, Taoyuan, 333, Taiwan.
| | - Wen-Jer Chen
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fu-Shin Street Kweishian, Taoyuan, 333, Taiwan
| | - Shiny Chih-Hsuan Wu
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fu-Shin Street Kweishian, Taoyuan, 333, Taiwan
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Doodkorte RJP, Roth AK, Jacobs E, Arts JJC, Willems PC. Biomechanical Evaluation of Semi-rigid Junctional Fixation Using a Novel Cable Anchor System to Prevent Proximal Junctional Failure in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:E415-E422. [PMID: 34559764 DOI: 10.1097/brs.0000000000004228] [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] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A porcine cadaveric biomechanical study. OBJECTIVE To biomechanically evaluate a novel Cable Anchor System as semi-rigid junctional fixation technique for the prevention of proximal junctional failure after adult spinal deformity surgery and to make a comparison to alternative promising prophylactic techniques. SUMMARY OF BACKGROUND DATA The abrupt change of stiffness at the proximal end of a pedicle screw construct is a major risk factor for the development of proximal junctional failure after adult spinal deformity surgery. A number of techniques that aim to provide a gradual transition zone in range of motion (ROM) at the proximal junction have previously been studied. In this study, the design of a novel Cable Anchor System, which comprises a polyethylene cable for rod fixation, is assessed. METHODS Ten T6-T13 porcine spine segments were subjected to cyclic 4 Nm pure-moment loading. The following conditions were tested: uninstrumented, 3 level pedicle screw fixation (PSF), and PSF with supplementary Cable Anchors applied proximally at 1-level (Anchor1) or 2-levels (Anchor2), transverse process hooks (TPH), and 2-level sublaminar tapes (Tape2). The normalized segmental range of motion in the junctional zone was compared using one-way analysis of variance and linear regression. RESULTS Statistical comparison at the level proximal to PSF showed significantly lower ROMs for all techniques compared to PSF fixation alone in all movement directions. Linear regression demonstrated a higher linearity for Anchor1 (0.820) and Anchor2 (0.923) in the junctional zone in comparison to PSF (1-level: 0.529 and 2-level: 0.421). This linearity was similar to the compared techniques (TPH and Tape2). CONCLUSION The Cable Anchor System presented in this study demonstrated a gradual ROM transition zone at the proximal end of a rigid pedicle screw construct similar to TPH and 2-level sublaminar tape semi-rigid junctional fixation constructs, while providing the benefit of preserving the posterior ligament complex.Level of Evidence: 5.
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Affiliation(s)
- Remco J P Doodkorte
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
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Liao JC, Chen WJ. The Influences of Spinopelvic Parameters and Associated Factors on Development of Proximal Instrumented Fracture After Posterior Instrumentation. World Neurosurg 2021; 157:e308-e315. [PMID: 34648985 DOI: 10.1016/j.wneu.2021.10.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate influences of spinopelvic parameters, such as lumbar lordosis (LL) angles, pelvic incidence, sacral slope, pelvic tilt, and sagittal vertical axis, on development of the proximal junctional failure fracture type after posterior instrumentation. METHODS This retrospective 1:3 matched case-control cohort study included 24 patients who developed proximal instrumented fracture in the study group and 72 patients without proximal junctional failure in the control group. Weighted Charlson Comorbidity Index and bone mineral density with T-score were recorded. In addition to spinopelvic parameters, proximal local kyphosis (PLK), which refers to a kyphosis angle between the upper end plate of upper instrumented vertebra plus 1 level and the lower end plate of upper instrumented vertebra; pelvic incidence-LL mismatch; and spinopelvic realignment score were calculated. RESULTS More comorbidities (Charlson Comorbidity Index, P = 0.002) and poorer bone density (T-score, P = 0.001) were noted in the study group. Before surgery, the study group had significantly lower LL (P = 0.046) and sacral slope (P = 0.043) and significantly higher PLK (P < 0.001) and pelvic tilt (P = 0.044) than the control group. Postoperatively, the study group had significantly higher PLK (P < 0.001) and lower LL (P = 0.031) than the control group; the degree of pelvic incidence-LL mismatch (P = 0.007) remained significantly higher in the study group. Preoperative (P = 0.026) and postoperative (P = 0.045) spinopelvic realignment scores was worse in the study group. Multivariate analysis revealed that postoperative PLK was the most significant radiographic factor to predict proximal instrumented fracture (P = 0.002, odds ratio 1.140, 95% confidence interval). CONCLUSIONS In our experience, appropriate LL and lower PLK should be obtained at surgery to prevent development of instrumented fracture.
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Affiliation(s)
- Jen-Chung Liao
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Wen-Jer Chen
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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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.
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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
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Doodkorte RJP, Vercoulen TFG, Roth AK, de Bie RA, Willems PC. Instrumentation techniques to prevent proximal junctional kyphosis and proximal junctional failure in adult spinal deformity correction-a systematic review of biomechanical studies. Spine J 2021; 21:842-854. [PMID: 33482379 DOI: 10.1016/j.spinee.2021.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Correction of adult spinal deformity (ASD) by long segment instrumented spinal fusion is an increasingly common surgical intervention. However, it is associated with high rates of complications and revision surgery, especially in the elderly patient population. The high construct stiffness of instrumented thoracolumbar spinal fusion has been postulated to lead to a higher incidence of proximal junctional kyphosis (PJK) and failure (PJF). Several cadaveric biomechanical studies have reported on surgical techniques to reduce the incidence of PJF/PJK. As yet, no overview has been made of these biomechanical studies. PURPOSE To summarize the evidence of all biomechanical studies that have assessed techniques to reduce PJK/PJF following long segment instrumented spinal fusion in the ASD patient population. STUDY DESIGN A systematic review. METHODS EMBASE and MEDLINE databases were searched for human and animal cadaveric biomechanical studies investigating the effect of various surgical techniques to reduce PJK/PJF following long segment instrumented thoracolumbar spinal fusion in the adult patient population. Studied techniques, biomechanical test methods, range of motion (ROM), intervertebral disc pressure (IDP) and other relevant outcome parameters were documented. RESULTS Twelve studies met the inclusion criteria. Four of these studies included non-human cadaveric material. One study investigated the prophylactic application of cement augmentation (vertebroplasty), whereas the remaining studies investigated semi-rigid junctional fixation techniques to achieve a gradual transition zone of forces at the proximal end of a fusion construct, so-called topping-off. An increased gradual transition zone in terms of ROM compared to pedicle screw constructs was demonstrated for sublaminar tethers, sublaminar tape, pretensioned suture loops, transverse hooks and laminar hooks. Furthermore, reduced IDP was found after the application of sublaminar tethers, suture loops, sublaminar tapes and laminar hooks. Finally, two-level prophylactic vertebroplasty resulted in a lower incidence of vertebral compression fractures in a flexion-compression experiment. CONCLUSIONS A variety of techniques, involving either posterior semi-rigid junctional fixation or the reinforcement of vertebral bodies, has been biomechanically assessed. However, the low number of studies and variation in study protocols hampers direct comparison of different techniques. Furthermore, determination of what constitutes an optimal gradual transition zone and its translation to clinical practice, would aid comparison and further development of different semi-rigid junctional fixation techniques. Even though biomechanics are extremely important in the development of PJK/PJF, patient-specific factors should always be taken into account on a case-by-case basis when considering to apply a semi-rigid junctional fixation technique.
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Affiliation(s)
- Remco J P Doodkorte
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, 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
| | - Alex K Roth
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Rob A de Bie
- Department of Epidemiology, Research School CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P. Debyeplein1, 6229 HA, Maastricht, The Netherlands
| | - Paul C Willems
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Doodkorte RJP, Belda R, Roth AK, van Rietbergen B, Arts JJ, Lataster LMA, van Rhijn LW, Willems PC. Ultra-high-molecular-weight polyethylene sublaminar tape as semirigid fixation or pedicle screw augmentation to prevent failure in long-segment spine surgery: an ex vivo biomechanical study. J Neurosurg Spine 2020; 34:236-244. [PMID: 33126215 DOI: 10.3171/2020.6.spine20605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complications after adult spinal deformity surgery are common, with implant-related complications occurring in up to 27.8% of cases. Sublaminar wire fixation strength is less affected by decreasing trabecular bone density in comparison to pedicle screw (PS) fixation due to the predominant cortical bone composition of the lamina. Sublaminar fixation may thus aid in decreasing implant-related complications. The goal of this study was to compare fixation characteristics of titanium sublaminar cables (SCs), ultra-high-molecular-weight polyethylene (UHMWPE) tape, PSs, and PSs augmented with UHMWPE tape in an ex vivo flexion-bending setup. METHODS Thirty-six human cadaver vertebrae were stratified into 4 different fixation groups: UHMWPE sublaminar tape (ST), PS, metal SC, and PS augmented with ST (PS + ST). Individual vertebrae were embedded in resin, and a flexion-bending moment was applied that closely resembles the in vivo loading pattern at transitional levels of spinal instrumentation. RESULTS The failure strength of PS + ST (4522 ± 2314 N) was significantly higher compared to the SC (2931 ± 751 N) and PS (2678 ± 827 N) groups, which had p values of 0.028 and 0.015, respectively (all values expressed as the mean ± SD). Construct stiffness was significantly higher for the PS groups compared to the stand-alone sublaminar wiring groups (p = 0.020). In contrast to SC, ST did not show any case of cortical breach. CONCLUSIONS The higher failure strength of PS + ST compared to PS indicates that PS augmentation with ST may be an effective measure to reduce the incidence of screw pullout, even in osteoporotic vertebrae. Moreover, the lower stiffness of sublaminar fixation techniques and the absence of damage to the cortices in the ST group suggest that ST as a stand-alone fixation technique in adult spinal deformity surgery may also be clinically feasible and offer clinical benefits.
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Affiliation(s)
- Remco J P Doodkorte
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ricardo Belda
- 2Centre of Research in Mechanical Engineering-CIIM, Department of Mechanical Engineering and Materials, Universitat Politècnica de València, Spain
| | - Alex K Roth
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bert van Rietbergen
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- 3Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven; and
| | - Jacobus J Arts
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- 3Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven; and
| | - L M Arno Lataster
- 4Department of Anatomy and Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Lodewijk W van Rhijn
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul C Willems
- 1Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
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Letter to the Editor concerning "Strap stabilization for proximal junctional kyphosis prevention in instrumented posterior spinal fusion" by Rodriguez-Fontan F, et al. (Eur Spine J; [2020]: 1287-1296, https://doi.org/10.1007/s00586-020-06,291-0). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2406. [PMID: 32720124 DOI: 10.1007/s00586-020-06545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 06/29/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
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Rosinski A, Odeh K, Ungurean V, Leasure J, Kondrashov D. Non-Pedicular Fixation Techniques for the Treatment of Spinal Deformity: A Systematic Review. JBJS Rev 2020; 8:e0150. [PMID: 32427778 DOI: 10.2106/jbjs.rvw.19.00150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND In recent years, the use of pedicle screws has become the gold standard for achieving stable, 3-column fixation of the spine. However, pedicle screw placement may not always be ideal, such as in adolescent idiopathic scoliosis, because of pedicle morphology. An understanding of the alternatives to pedicle screw fixation is therefore important in the treatment of patients with spinal deformity. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with non-pedicular fixation techniques of the thoracolumbar spine. METHODS Comprehensive literature searches of PubMed, Scopus, and Web of Science databases were performed for 10 methods of non-pedicular fixation. Articles published between January 1, 1990, and June 1, 2019, were considered. Non-English-language articles and studies involving fixation of the cervical spine were excluded from our review. RESULTS After reviewing >1,600 titles and abstracts pertaining to non-pedicular fixation, a total of 213 articles met our inclusion criteria. Non-pedicular fixation may be preferred in certain cases of spinal deformity and may provide stronger fixation in osteoporotic bone. The use of non-pedicular fixation techniques is often limited by the inability to place multilevel constructs on intact posterior elements. Additionally, some methods of non-pedicular fixation, such as spinous process tethering, primarily have utility for the end of constructs to minimize junctional problems. CONCLUSIONS Pedicle screws remain the anchor of choice in spinal deformity surgery because of their ability to engage all 3 columns of the spine and provide safe correction in all 3 planes. Nevertheless, non-pedicular fixation may be useful in cases in which pedicle screw placement is extremely difficult. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | - Jeremi Leasure
- The Taylor Collaboration, San Francisco, California.,San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Dimitriy Kondrashov
- The Taylor Collaboration, San Francisco, California.,San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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Matsukawa K, Kato T, Mobbs R, Yato Y, Asazuma T. Combination of sacral-alar-iliac screw and cortical bone trajectory screw techniques for lumbosacral fixation: technical note. J Neurosurg Spine 2020; 33:186-191. [PMID: 32197252 DOI: 10.3171/2020.1.spine191420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbosacral fixation plays an important role in the management of devastating spinal pathologies, including osteoporosis, fracture, infection, tumor resection, and spinal deformities, which require long-segment fusion constructs to the sacrum. The sacral-alar-iliac (SAI) screw technique has been developed as a promising solution to facilitate both minimal invasiveness and strong fixation. The rationale for SAI screw insertion is a medialized entry point away from the ilium and in line with cranial screws. The divergent screw path of the cortical bone trajectory (CBT) provides a higher amount of cortical bone purchase and strong screw fixation and has the potential to harmoniously align with SAI screws due to its medial starting point. However, there has been no report on the combination of these two techniques. The objective of this study was to assess the feasibility of this combination technique. METHODS The subjects consisted of 17 consecutive patients with a mean age of 74.2 ± 4.7 years who underwent posterior lumbosacral fixation for degenerative spinal pathologies using the combination of SAI and CBT fixation techniques. There were 8 patients with degenerative scoliosis, 7 with degenerative kyphosis, 1 with an osteoporotic vertebral fracture at L5, and 1 with vertebral metastasis at L5. Fusion zones included T10-sacrum in 13 patients, L2-sacrum in 2, and L4-sacrum in 2. RESULTS No patients required complicated rod bending or the use of a connector for rod assembly in the lumbosacral region. Postoperative CT performed within a week after surgery showed that all lumbosacral screws were in correct positions and there was no incidence of neurovascular injuries. The lumbosacral bone fusion was confirmed in 81.8% of patients at 1-year follow-up based on fine-cut CT scanning. No patient showed a significant loss of spinal alignment or rod fracture in the lumbosacral transitional region. CONCLUSIONS This is the first paper on the feasibility of a combination technique using SAI and CBT screws. This technique could be a valid option for lumbosacral fixation due to the ease of rod placement with potential reductions in operative time and blood loss.
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Affiliation(s)
- Keitaro Matsukawa
- 1Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; and
| | - Takashi Kato
- 1Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; and
| | - Ralph Mobbs
- 2Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, Sydney, Australia
| | - Yoshiyuki Yato
- 1Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; and
| | - Takashi Asazuma
- 1Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; and
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Smith LGF, Hoang N, Shaikhouni A, Viljoen S. Sublaminar polyester bands as a salvage fixation method in the cervical spine: novel application in two patients. J Neurosurg Spine 2019; 30:772-776. [PMID: 30835703 DOI: 10.3171/2018.12.spine181147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/21/2018] [Indexed: 11/06/2022]
Abstract
Pedicle and lateral mass screws are the most common means of rigid fixation in posterior cervical spine fusions. Various other techniques such as translaminar screw placement, paravertebral foramen screw fixation, sublaminar and spinous process wiring, cement augmentation, and others have been developed for primary fixation or as salvage methods. Use of these techniques can be limited by a prior history of osteotomies, poor bone density, destruction of the bone-screw interface, and unfavorable vascular and osseous anatomy.Here, the authors report on the novel application of cervical sublaminar polyester bands as an adjunct salvage method or additional fixation point used with traditional methods in the revision of prior constructs. While sublaminar polyester bands have been used for decades in pediatric scoliosis surgery in the thoracolumbar spine, they have yet to be utilized as a method of fixation in the cervical spine. In both cases described here, sublaminar banding proved crucial for fixation points where traditional fixation techniques would have been less than ideal. Further study is required to determine the full application of sublaminar polyester bands in the cervical spine as well as its outcomes.
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Affiliation(s)
- Luke G F Smith
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
| | - Nguyen Hoang
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
| | - Ammar Shaikhouni
- 2Division of Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephanus Viljoen
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
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Viswanathan VK, Minnema AJ, Viljoen S, Farhadi HF. Sublaminar banding as an adjunct to pedicle screw-rod constructs: a review and technical note on novel hybrid constructs in spinal deformity surgery. J Neurosurg Spine 2019; 30:807-813. [PMID: 30835710 DOI: 10.3171/2018.11.spine181154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
Sublaminar implants that encircle cortical bone are well-established adjuncts to pedicle screw-rod constructs in pediatric deformity surgery. Sublaminar bands (SLBs) in particular carry the advantage of relatively greater bone contact surface area as compared to wires and pullout loads that are independent of bone mineral density, in contrast to pedicle screws. Whereas the relevant technical considerations have been reported for pediatric deformity correction, an understanding of the relative procedural specifics of these techniques is missing for adult spinal deformity (ASD), despite several case series that have used distinct posterior tethering techniques for proximal junctional kyphosis prevention. In this paper, the authors summarize the relevant literature and describe a novel technique wherein bilateral tensioned SLBs are introduced at the nonfused proximal junctional level of long-segment ASD constructs.
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