TY - JOUR
T1 - Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection
AU - Line, Breton G.
AU - Bess, Shay
AU - Lafage, Renaud
AU - Lafage, Virgine
AU - Schwab, Frank
AU - Ames, Christopher
AU - Kim, Han Jo
AU - Kelly, Michael
AU - Gupta, Munish
AU - Burton, Douglas
AU - Hart, Robert
AU - Klineberg, Eric
AU - Kebaish, Khaled
AU - Hostin, Richard
AU - Mundis, Gregory
AU - Eastlack, Robert
AU - Shaffrey, Christopher
AU - Smith, Justin S.
N1 - Funding Information:
From the *Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke’s Medical Center, Denver, CO; †Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY; zDepartment of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA; §Washington University, St. Louis, MO; {Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS; ||Swedish Neuroscience Institute, Seattle, WA; **Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA; ††Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; zzBaylor Scoliosis Center, Plano, TX; §§San Diego Center for Spinal Disorders, La Jolla, CA; and {{Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA. Acknowledgment date: May 3, 2019. First revision date: July 22, 2019. Acceptance date: August 15, 2019. The manuscript submitted does not contain information about medical device(s)/drug(s). Depuy Synthes Spine, K2 Medical, and Nuvasive provided research support in part for this study for the International Spine Study Group Foundation including financial support for study patient enrollment and data analysis.
Publisher Copyright:
© 2019 Wolters Kluwer Health, Inc.
PY - 2020/2/15
Y1 - 2020/2/15
N2 - Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database.Objective.Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data.PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) versus within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF. Level of Evidence: 3.
AB - Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database.Objective.Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data.PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) versus within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF. Level of Evidence: 3.
KW - adult spinal deformity
KW - age-adjusted sagittal alignment
KW - prophylaxis
KW - proximal junctional failure
KW - proximal junctional kyphosis
UR - http://www.scopus.com/inward/record.url?scp=85072264943&partnerID=8YFLogxK
U2 - 10.1097/BRS.0000000000003249
DO - 10.1097/BRS.0000000000003249
M3 - Article
C2 - 31524819
AN - SCOPUS:85072264943
SN - 0362-2436
VL - 45
SP - 258
EP - 267
JO - Spine
JF - Spine
IS - 4
ER -