Browsing by Subject "PJK"

Now showing 1 - 5 of 5
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    ItemOpen Access
    Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques.
    (Journal of neurosurgery. Spine, 2023-06) Tretiakov, Peter S; Lafage, Renaud; Smith, Justin S; Line, Breton G; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey; Protopsaltis, Themistocles; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert K; Mundis, Gregory; Nunley, Pierce D; Klineberg, Eric O; Kebaish, Khaled; Lewis, Stephen; Lenke, Lawrence; Hostin, Richard; Gupta, Munish C; Ames, Christopher P; Hart, Robert A; Burton, Douglas; Shaffrey, Christopher I; Schwab, Frank; Bess, Shay; Kim, Han Jo; Lafage, Virginie; Passias, Peter G

    Objective

    The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF).

    Methods

    Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05.

    Results

    Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit.

    Conclusions

    PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.
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    ItemOpen Access
    Clinical outcomes and proximal junctional failure in adult spinal deformity patients corrected to normative alignment versus functional alignment.
    (Journal of neurosurgery. Spine, 2023-07) Protopsaltis, Themistocles S; Ani, Fares; Soroceanu, Alexandra; Lafage, Renaud; Kim, Han Jo; Balouch, Eaman; Norris, Zoe; Smith, Justin S; Daniels, Alan H; Klineberg, Eric O; Ames, Christopher P; Hart, Robert; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lenke, Lawrence G; Lafage, Virginie; Gupta, Munish C

    Objective

    The objective of this study was to explore the rate of proximal junctional failure (PJF) and functional outcomes of normative alignment goals compared with alignment targets based on age-appropriate physical function.

    Methods

    Baseline relationships between age, pelvic incidence (PI), and a component of the T1 pelvic angle (TPA) within the fusion were analyzed in adult spinal deformity (ASD) patients and compared with those of asymptomatic patients. Linear regression modeling was used to determine alignment based on PI and age in asymptomatic patients (normative alignment), and in ASD patients, alignment corresponding to age-appropriate functional status (functional alignment). A cohort of 288 ASD patients was split into two groups based on whether the patient was closer to their normative or functional alignment goal at their 6-week postoperative radiographic follow-up. The rates of proximal junctional kyphosis (PJK) and PJF were determined for each cohort.

    Results

    In the 288 ASD patients included in this pre- to postoperative analysis, there was no difference in baseline alignment or health-related quality of life (HRQOL) between the normative alignment and functional alignment groups. At 6 weeks, patients with normative alignment had a smaller TPA (4.45° vs 14.1°) and PI minus lumbar lordosis (-7.24° vs 7.4°) (both p < 0.0001) and higher PJK (40% vs 27.2%, p = 0.03) and PJF (17% vs 6.8%, p = 0.008) rates than patients with functional alignment.

    Conclusions

    Correction in ASD patients to normative alignment resulted in higher rates of PJK and PJF without improvements in HRQOL. Correction in ASD patients to functional alignment that mirrors the physical function of their age-matched asymptomatic peers is recommended.
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    ItemOpen Access
    Predictive role of global spinopelvic alignment and upper instrumented vertebra level in symptomatic proximal junctional kyphosis in adult spinal deformity.
    (Journal of neurosurgery. Spine, 2023-08) Ye, Jichao; Gupta, Sachin; Farooqi, Ali S; Yin, Tsung; Soroceanu, Alex; Schwab, Frank J; Lafage, Virginie; Kelly, Michael P; Kebaish, Khaled; Hostin, Richard; Gum, Jeffrey L; Smith, Justin S; Shaffrey, Christopher I; Scheer, Justin K; Protopsaltis, Themistocles S; Passias, Peter G; Klineberg, Eric O; Kim, Han Jo; Hart, Robert A; Hamilton, D Kojo; Ames, Christopher P; Gupta, Munish C

    Objective

    The authors of this study sought to evaluate the predictive role of global sagittal alignment and upper instrumented vertebra (UIV) level in symptomatic proximal junctional kyphosis (PJK) among patients with adult spinal deformity (ASD).

    Methods

    Data on ASD patients who had undergone fusion of ≥ 5 vertebrae from 2008 to 2018 and with a minimum follow-up of 1 year were obtained from a prospectively collected multicenter database and evaluated (n = 1312). Radiographs were obtained preoperatively and at 6 weeks, 6 months, 1 year, 2 years, and 3 years postoperatively. The 22-Item Scoliosis Research Society Patient Questionnaire Revised (SRS-22r) scores were collected preoperatively, 1 year postoperatively, and 2 years postoperatively. Symptomatic PJK was defined as a kyphotic increase > 20° in the Cobb angle from the UIV to the UIV+2. At 6 weeks postoperatively, sagittal parameters were evaluated and patients were categorized by global alignment and proportion (GAP) score/category and SRS-Schwab sagittal modifiers. Patients were stratified by UIV level: upper thoracic (UT) UIV ≥ T8 or lower thoracic (LT) UIV ≤ T9.

    Results

    Patients who developed symptomatic PJK (n = 260) had worse 1-year postoperative SRS-22r mental health (3.70 vs 3.86) and total (3.56 vs 3.67) scores, as well as worse 2-year postoperative self-image (3.45 vs 3.65) and satisfaction (4.03 vs 4.22) scores (all p ≤ 0.04). In the whole study cohort, patients with PJK had less pelvic incidence-lumbar lordosis (PI-LL) mismatch (-0.24° vs 3.29°, p < 0.001) but no difference in their GAP score/category or SRS-Schwab sagittal modifiers compared with the patients without PJK. Regression showed a higher risk of PJK with a pelvic tilt (PT) grade ++ (OR 2.35) and less risk with a PI-LL grade ++ (OR 0.35; both p < 0.01). When specifically analyzing the LT UIV cohort, patients with PJK had a higher GAP score (5.66 vs 4.79), greater PT (23.02° vs 20.90°), and less PI-LL mismatch (1.61° vs 4.45°; all p ≤ 0.02). PJK patients were less likely to be proportioned postoperatively (17.6% vs 30.0%, p = 0.015), and regression demonstrated a greater PJK risk with severe disproportion (OR 1.98) and a PT grade ++ (OR 3.15) but less risk with a PI-LL grade ++ (OR 0.45; all p ≤ 0.01). When specifically evaluating the UT UIV cohort, the PJK patients had less PI-LL mismatch (-2.11° vs 1.45°) but no difference in their GAP score/category. Regression showed a greater PJK risk with a PT grade + (OR 1.58) and a decreased risk with a PI-LL grade ++ (OR 0.21; both p < 0.05).

    Conclusions

    Symptomatic PJK leads to worse patient-reported outcomes and is associated with less postoperative PI-LL mismatch and greater postoperative PT. A worse postoperative GAP score and disproportion are only predictive of symptomatic PJK in patients with an LT UIV.
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    ItemOpen Access
    The impact of baseline cervical malalignment on the development of proximal junctional kyphosis following surgical correction of thoracolumbar adult spinal deformity.
    (Journal of neurosurgery. Spine, 2023-07) Passfall, Lara; Imbo, Bailey; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Line, Breton; Schoenfeld, Andrew J; Protopsaltis, Themistocles; Daniels, Alan H; Kebaish, Khaled M; Gum, Jeffrey L; Koller, Heiko; Hamilton, D Kojo; Hostin, Richard; Gupta, Munish; Anand, Neel; Ames, Christopher P; Hart, Robert; Burton, Douglas; Schwab, Frank J; Shaffrey, Christopher I; Klineberg, Eric O; Kim, Han Jo; Bess, Shay; Passias, Peter G

    Objective

    The objective of this study was to identify the effect of baseline cervical deformity (CD) on proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients with adult spinal deformity (ASD).

    Methods

    This study was a retrospective analysis of a prospectively collected, multicenter database comprising ASD patients enrolled at 13 participating centers from 2009 to 2018. Included were ASD patients aged > 18 years with concurrent CD (C2-7 kyphosis < -15°, T1S minus cervical lordosis > 35°, C2-7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, McGregor's slope > 20°, or C2-T1 kyphosis > 15° across any three vertebrae) who underwent surgery. Patients were grouped according to four deformity classification schemes: Ames and Passias CD modifiers, sagittal morphotypes as described by Kim et al., and the head versus trunk balance system proposed by Mizutani et al. Mean comparison tests and multivariable binary logistic regression analyses were performed to assess the impact of these deformity classifications on PJK and PJF rates up to 3 years following surgery.

    Results

    A total of 712 patients with concurrent ASD and CD met the inclusion criteria (mean age 61.7 years, 71% female, mean BMI 28.2 kg/m2, and mean Charlson Comorbidity Index 1.90) and underwent surgery (mean number of levels fused 10.1, mean estimated blood loss 1542 mL, and mean operative time 365 minutes; 70% underwent osteotomy). By approach, 59% of the patients underwent a posterior-only approach and 41% underwent a combined approach. Overall, 277 patients (39.1%) had PJK by 1 year postoperatively, and an additional 189 patients (26.7%) developed PJK by 3 years postoperatively. Overall, 65 patients (9.2%) had PJF by 3 years postoperatively. Patients classified as having a cervicothoracic deformity morphotype had higher rates of early PJK than flat neck deformity and cervicothoracic deformity patients (p = 0.020). Compared with the head-balanced patients, trunk-balanced patients had higher rates of PJK and PJF (both p < 0.05). Examining Ames modifier severity showed that patients with moderate and severe deformity by the horizontal gaze modifier had higher rates of PJK (p < 0.001).

    Conclusions

    In patients with concurrent cervical and thoracolumbar deformities undergoing isolated thoracolumbar correction, the use of CD classifications allows for preoperative assessment of the potential for PJK and PJF that may aid in determining the correction of extending fusion levels.
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    ItemOpen Access
    Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery.
    (Journal of neurosurgery. Spine, 2023-06) Ye, Jichao; Gupta, Sachin; Farooqi, Ali S; Yin, Tsung-Cheng; Soroceanu, Alex; Schwab, Frank J; Lafage, Virginie; Kelly, Michael P; Kebaish, Khaled; Hostin, Richard; Gum, Jeffrey L; Smith, Justin S; Shaffrey, Christopher I; Scheer, Justin K; Protopsaltis, Themistocles S; Passias, Peter G; Klineberg, Eric O; Kim, Han Jo; Hart, Robert A; Hamilton, D Kojo; Ames, Christopher P; Gupta, Munish C

    Objective

    Multiple rods are utilized in adult spinal deformity (ASD) surgery to increase construct stiffness. However, the impact of multiple rods on proximal junctional kyphosis (PJK) is not well established. This study aimed to investigate the impact of multiple rods on PJK incidence in ASD patients.

    Methods

    ASD patients from a prospective multicenter database with a minimum follow-up of 1 year were retrospectively reviewed. Clinical and radiographic data were collected preoperatively, at 6 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, and at every subsequent year postoperatively. PJK was defined as a kyphotic increase of > 10° in the Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 as compared with preoperative values. Demographic data, radiographic parameters, and PJK incidence were compared between the multirod and dual-rod patient cohorts. PJK-free survival analysis was performed using Cox regression to control for demographic characteristics, comorbidities, level of fusion, and radiographic parameters.

    Results

    Overall, 307/1300 (23.62%) cases utilized multiple rods. Cases with multiple rods were more likely to be revisions (68.4% vs 46.5%, p < 0.001), to be posterior only (80.7% vs 61.5%, p < 0.001), involve more levels of fusion (mean 11.73 vs 10.60, p < 0.001), and include 3-column osteotomy (42.9% vs 17.1%, p < 0.001). Patients with multiple rods also had greater preoperative pelvic retroversion (mean pelvic tilt 27.95° vs 23.58°, p < 0.001), greater thoracolumbar junction kyphosis (-15.9° vs -11.9°, p = 0.001), and more severe sagittal malalignment (C7-S1 sagittal vertical axis 99.76 mm vs 62.23 mm, p < 0.001), all of which corrected postoperatively. Patients with multiple rods had similar incidence rates of PJK (58.6% vs 58.1%) and revision surgery (13.0% vs 17.7%). The PJK-free survival analysis demonstrated equivalent PJK-free survival durations among the patients with multiple rods (HR 0.889, 95% CI 0.745-1.062, p = 0.195) after controlling for demographic and radiographic parameters. Further stratification based on implant metal type demonstrated noninferior PJK incidence rates with multiple rods in the titanium (57.1% vs 54.6%, p = 0.858), cobalt chrome (60.5% vs 58.7%, p = 0.646), and stainless steel (20% vs 63.7%, p = 0.008) cohorts.

    Conclusions

    Multirod constructs for ASD are most frequently utilized in revision, long-level reconstructions with 3-column osteotomy. The use of multiple rods in ASD surgery does not result in an increased incidence of PJK and is not affected by rod metal type.