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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Sardi JP, Lazaro B, Smith JS, Kelly MP, Dial B, Hills J, Yanik EL, Gupta M, Baldus CR, Yen CP, Lafage V, Ames CP, Bess S, Schwab F, Shaffrey CI, Bridwell KH. Rod fractures in thoracolumbar fusions 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; 38:217-229. [PMID: 36461845 DOI: 10.3171/2022.8.spine22423] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/04/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Previous reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up. METHODS Patient records were obtained from the Adult Symptomatic Lumbar Scoliosis-1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40-80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery. RESULTS Inclusion criteria were met by 160 patients (median age 62 years, IQR 55.7-67.9 years). At a median follow-up of 5.1 years (IQR 3.8-6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9-4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196-3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005-1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8-6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18-0.84, p = 0.016). CONCLUSIONS This study provides what is to the authors' knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.
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Affiliation(s)
- Juan Pablo Sardi
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bruno Lazaro
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Michael P Kelly
- 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
| | - Elizabeth L Yanik
- 2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Munish 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 Health System, 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
- 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
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Dial BL, Hills JM, Smith JS, Sardi JP, Lazaro B, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Lafage R, Kelly MP, Bridwell KH. The impact of lumbar alignment targets on mechanical complications after adult lumbar scoliosis surgery. Eur Spine J 2022; 31:1573-1582. [PMID: 35428916 DOI: 10.1007/s00586-022-07200-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to determine the discriminatory ability of age-adjusted alignment offset and the global alignment and proportion (GAP) score parameters to predict postoperative mechanical complications. METHODS Surgical patients from the Adult Symptomatic Lumbar Scoliosis cohort were reviewed at 2 year follow up. Age-adjusted alignment offsets and GAP parameters were calculated for each patient. A series of nonlinear logistic regression models were fit, and the odds of mechanical complications were calculated. The discriminatory ability of the GAP score, GAP score parameters, and age-adjusted alignment offsets were determined plotting receiver operative characteristic (ROC) with the C statistic (AUC). RESULTS A total of 165 patients were included. A total of 49 mechanical complications occurred in 41 patients (21 proximal junctional kyphosis and 28 pseudoarthrosis). The GAP score had no discriminatory ability in this cohort. Relative lumbar lordosis 15 degrees greater than ideal lumbar lordosis was associated with greater mechanical complications. A lumbar distribution index of 90% was associated with fewer mechanical complications compared to a lumbar distribution index of 65%. Age-adjusted offset alignment targets had no discriminatory ability to predict mechanical complications. CONCLUSION Radiographic alignment targets using either age-adjusted alignment target offset or GAP score parameters had minimal ability to predict mechanical complications in isolation. Mechanical complications following adult spinal deformity surgery are complex, and patient factors play a critical role. Clinical trial registeration This study was registered at ClinicalTrials.gov (number NCT00854828) in March 2009.
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Affiliation(s)
- Brian L Dial
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Jeffrey M Hills
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Juan Pablo Sardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Bruno Lazaro
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Frank J Schwab
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, University of California, San Diego, 3020 Children's Way, San Diego, CA, 92123, USA.
| | - Keith H Bridwell
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
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Cappelier JM, Lazaro B, Rossero A, Fernandez-Astorga A, Federighi M. Double staining (CTC-DAPI) for detection and enumeration of viable but non-culturable Campylobacter jejuni cells. Vet Res 1997; 28:547-55. [PMID: 9428148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Direct microscopic enumeration of viable Campylobacter jejuni cells (ie, respiring bacteria) were performed in both culturable and non-culturable states. Five different C jejuni strains were used, including a reference strain, ATCC 33291. Cells from all five strains were incubated alone with 5-cyano-2,3-ditolyl tetrazolium chloride (CTC), a redox dye. It was reduced by an electron transport chain to an insoluble red fluorescent CTC formazan salt, which accumulated intracellularly. The presence of these red CTC crystals in the bacteria cells was indicative of cellular respiratory activity. Counterstaining with 4'-6 diamino-2 phenylindole (DAPI), which fluoresces in blue, made a suitable contrast and allowed simultaneous enumeration of total and viable bacteria on a single filter. Four hours of incubation with 5 mM CTC under a microaerobic atmosphere was found to be the optimal condition yielding the maximum number of respiring cells (both culturable and non-culturable). When used in combination with standard culture techniques, double staining makes it possible to monitor the viable but non-culturable cells of jejuni obtained by starvation more easily than with the direct viable count procedure.
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Affiliation(s)
- J M Cappelier
- Ecole nationale vétérinaire de Nantes, unité associée Inra d'hygiène alimentaire, France
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