TY - JOUR
T1 - Proximal junctional failure in primary thoracolumbar fusion/fixation to the sacrum/pelvis for adult symptomatic lumbar scoliosis
T2 - long-term follow-up of a prospective multicenter cohort of 160 patients
AU - Lazaro, Bruno
AU - Sardi, Juan Pablo
AU - Smith, Justin S.
AU - Kelly, Michael P.
AU - Yanik, Elizabeth L.
AU - Dial, Brian
AU - Hills, Jeffrey
AU - Gupta, Munish C.
AU - Baldus, Christine R.
AU - Yen, Chun Po
AU - Lafage, Virginie
AU - Ames, Christopher P.
AU - Bess, Shay
AU - Schwab, Frank
AU - Shaffrey, Christopher I.
AU - Bridwell, Keith H.
N1 - Funding Information:
This trial was funded by the National Institute of Arthritis
Funding Information:
Dr. Smith is a consultant for Zimmer Biomet, Carlsmed, DePuy Synthes, NuVasive, Stryker, SeaSpine, and Cerapedics; receives royalties from Zimmer Biomet, NuVasive, and Thieme; owns stock in Alphatec and NuVasive; receives support from DePuy Synthes/ISSGF, NuVasive, and AO Spine for non–study-related clinical research effort; and receives fellowship support from AO Spine. Dr. Kelly receives honoraria from Wolters Kluwer. Dr. Gupta receives royalties from DePuy, Innomed, and Globus; is a consultant for DePuy, Medtronic, Globus, and Alphatec (2019); owns stock in J&J; receives honoraria from AO Spine, Wright State, LSU, and Malaysia Spine Society; serves on the board of directors for and has received travel funds from the SRS; has received travel funds from DePuy, Medtronic, Alphatec (2019), Medicrea (2019), Mizuho (2019), AO Spine, Globus, and Zimmer Biomet; and volunteers as a scientific advisor to the National Health Spine Foundation. Dr. Yen is a consultant for NuVasive. Dr. Lafage receives honoraria from Stryker, Implanet, and J&J; receives royalties from NuVasive; is a consultant for Globus and Alphatec; has ownership of VFT Solutions and See Sine LLC; and serves on committees for the International Spine Study Group and SRS. Dr. Ames receives royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; is a consultant for DePuy Synthes, Medtronic, Medicrea, K2M, Carlsmed, and Agada Medical; receives research support from Titan Spine, DePuy Synthes, and International Spine Study Group; serves on editorial board of Operative Neurosurgery; serves on executive committee for International Spine Study Group; serves as director of Global Spinal Analytics; and serves as chair of the SRS Safety and Value Committee. Dr. Bess is a consultant for Atec, Mirus, Cerepedics, and Amgen; holds a patent with Stryker and NuVasive; received support from DePuy Synthes, NuVasive, International Spine Study Group Foundation, and Stryker for the study described; receives support from DePuy Synthes, NuVasive, Stryker, Medtronic, Globus, SI Bone, SeaSpine, and Carlsmed for non–study-related effort; is on the speakers bureau of Atec; and receives royalties from Stryker and NuVasive. Dr. Schwab owns stock in VFT Solutions and SeaSpine; is a consultant for Zimmer Biomet, Medtronic, and Mainstay Medical; receives royalties from Zimmer Biomet and Medtronic; and serves as executive committee member for International Spine Study Group. Dr. Shaffrey is a consultant for NuVasive, Medtronic, SI Bone, and Proprio; owns stock in NuVasive and Proprio; holds patents with NuVasive, Medtronic, and SI Bone; and receives royalties from NuVasive and SI Bone.
Publisher Copyright:
© AANS 2023.
PY - 2023/3
Y1 - 2023/3
N2 - 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.
AB - 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.
KW - adult scoliosis
KW - complications
KW - lumbar
KW - proximal junctional failure
KW - proximal junctional kyphosis
KW - spinal alignment
KW - spinal instrumentation
KW - spine deformity
KW - spine surgery
UR - http://www.scopus.com/inward/record.url?scp=85149186685&partnerID=8YFLogxK
U2 - 10.3171/2022.9.SPINE22549
DO - 10.3171/2022.9.SPINE22549
M3 - Article
C2 - 36334285
AN - SCOPUS:85149186685
SN - 1547-5654
VL - 38
SP - 319
EP - 330
JO - Journal of Neurosurgery: Spine
JF - Journal of Neurosurgery: Spine
IS - 3
ER -