Abstract
Purpose
Proximal junctional kyphosis (PJK) is a common radiographic finding following long spinal fusions. Whether PJK leads to negative clinical outcome is currently debatable. A systematic review was performed to assess the prevalence, risk factors, and treatments of PJK.
Methods
Literature search was conducted on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials using the terms ‘proximal junctional kyphosis’ and ‘proximal junctional failure’. Excluding reviews, commentaries, and case reports, we analyzed 33 studies that reported the prevalence rate, risk factors, and discussions on PJK following spinal deformity surgery.
Results
The prevalence rates varied widely from 6 to 61.7 %. Numerous studies reported that clinical outcomes for patients with PJK were not significantly different from those without, except in one recent study in which adult patients with PJK experienced more pain. Risk factors for PJK included age at operation, low bone mineral density, shorter fusion constructs, upper instrumented vertebrae below L2, and inadequate restoration of global sagittal balance.
Conclusions
Prevalence of PJK following long spinal fusion for adult spinal deformity was high but not clinically significant. Careful and detailed preoperative planning and surgical execution may reduce PJK in adult spinal deformity patients.
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References
Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G (2006) Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis. Spine (Phila Pa 1976) 31:2359–2366
Hostin R, McCarthy I, O’Brien M, et al. (2012) Incidence, mode, and location of acute proximal junctional failures following surgical treatment for adult spinal deformity. Spine (Phila Pa 1976)
Yagi M, Akilah KB, Boachie-Adjei O (2011) Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976) 36:E60–E68
Hyun SJ, Rhim SC (2010) Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients : a long-term follow-up data. J Korean Neurosurg Soc 47:95–101
Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Koester L, Hensley M (2010) Proximal junctional vertebral fracture in adults after spinal deformity surgery using pedicle screw constructs: analysis of morphological features. Spine (Phila Pa 1976) 35:138–145
O’Leary PT, Bridwell KH, Lenke LG et al (2009) Risk factors and outcomes for catastrophic failures at the top of long pedicle screw constructs: a matched cohort analysis performed at a single center. Spine (Phila Pa 1976) 34:2134–2139
Hart RA, Prendergast MA, Roberts WG, Nesbit GM, Barnwell SL (2008) Proximal junctional acute collapse cranial to multi-level lumbar fusion: a cost analysis of prophylactic vertebral augmentation. Spine J 8:875–881
Maruo K, Ha Y, Inoue S et al (2013) Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity. Spine (Phila Pa 1976) 38:E1469–E1476
Lee GA, Betz RR, Clements DH 3rd, Huss GK (1999) Proximal kyphosis after posterior spinal fusion in patients with idiopathic scoliosis. Spine (Phila Pa 1976) 24:795–799
Bernhardt M, Bridwell KH (1989) Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine (Phila Pa 1976) 14:717–721
Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C II (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976) 30:1643–1649
Carman DL, Browne RH, Birch JG (1990) Measurement of scoliosis and kyphosis radiographs. Intraobserver and interobserver variation. J Bone Jt Surg Am 72:328–333
Helgeson MD, Shah SA, Newton PO et al (2010) Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation. Spine (Phila Pa 1976) 35:177–181
O’Shaughnessy BA, Bridwell KH, Lenke LG et al (2012) Does a long-fusion “T3-sacrum” portend a worse outcome than a short-fusion “T10-sacrum” in primary surgery for adult scoliosis? Spine 37:884–890
Bridwell KH, Lenke LG, Cho SK et al (2013) Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20° as a critical angle. Neurosurgery 72:899–906
Sacramento-Dominguez C, Vayas-Diez R, Coll-Mesa L et al (2009) Reproducibility measuring the angle of proximal junctional kyphosis using the first or the second vertebra above the upper instrumented vertebrae in patients surgically treated for scoliosis. Spine (Phila Pa 1976) 34:2787–2791
Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G (2008) Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976) 33:2179–2184
Yagi M, King AB, Boachie-Adjei O (2012) Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976) 37:1479–1489
Kim HJ, Bridwell KH, Lenke LG et al (2013) Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976) 38:896–901
Kim YJ, Bridwell KH, Lenke LG, Rhim S, Kim YW (2007) Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine (Phila Pa 1976) 32:2653–2661
Kuhns CA, Bridwell KH, Lenke LG et al (2007) Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5–S1 disc, minimum 5-year follow-up. Spine (Phila Pa 1976) 32:2771–2776
Scheer JK, Lafage V, Smith JS, et al. (2014) Maintenance of radiographic correction at 2 years following lumbar pedicle subtraction osteotomy is superior with upper thoracic compared with thoracolumbar junction upper instrumented vertebra. Eur Spine J
Fujimori T, Inoue S, Le H et al (2014) Long fusion from sacrum to thoracic spine for adult spinal deformity with sagittal imbalance: upper versus lower thoracic spine as site of upper instrumented vertebra. Neurosurg Focus 36:E9
Kim HJ, Boachie-Adjei O, Shaffrey CI et al (2014) Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis. Spine (Phila Pa 1976) 39:E795–E799
Ha Y, Maruo K, Racine L et al (2013) Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae. J Neurosurg Spine 19:360–369
Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C (2007) Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976) 32:2189–2197
Smith MW, Annis P, Lawrence BD, Daubs MD, Brodke DS (2013) Early proximal junctional failure in patients with preoperative sagittal imbalance. Evid Based Spine Care J 4:163–164
Yagi M, Rahm M, Gaines R et al (2014) Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity. Spine (Phila Pa 1976) 39:E607–E614
Hart R, McCarthy I, O’Brien M et al (2013) Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity. Spine (Phila Pa 1976) 38:E1223–E1227
Rose PS, Bridwell KH, Lenke LG et al (2009) Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine (Phila Pa 1976) 34:785–791
Cammarata M, Aubin CE, Wang X, Mac-Thiong JM (2014) Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976) 39:E500–E507
Thawrani DP, Glos DL, Coombs MT, Bylski-Austrow DI, Sturm PF (2014) Transverse process hooks at upper instrumented vertebra provide more gradual motion transition than pedicle screws. Spine (Phila Pa 1976) 39:E826–E832
Kim YJ, Lenke LG, Bridwell KH et al (2007) Proximal junctional kyphosis in adolescent idiopathic scoliosis after 3 different types of posterior segmental spinal instrumentation and fusions: incidence and risk factor analysis of 410 cases. Spine (Phila Pa 1976) 32:2731–2738
Yalcin N, Ozturk A, Ozkan Y et al (2011) The effects of zoledronic acid and hyperbaric oxygen on posterior lumbar fusion in a rabbit model. J Bone Jt Surg Br 93:793–800
Koo KH, Lee JH, Chang BS, Lee CK (2012) Effects of alendronate on lumbar posterolateral fusion using hydroxyapatite in rabbits. Artif Organs 36:1047–1055
Hirsch BP, Unnanuntana A, Cunningham ME, Lane JM (2013) The effect of therapies for osteoporosis on spine fusion: a systematic review. Spine J 13:190–199
Nagahama K, Kanayama M, Togawa D, Hashimoto T, Minami A (2011) Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial. J Neurosurg Spine 14:500–507
Nakao S, Minamide A, Kawakami M, Boden SD, Yoshida M (2011) The influence of alendronate on spine fusion in an osteoporotic animal model. Spine (Phila Pa 1976) 36:1446–1452
Takahata M, Ito M, Abe Y, Abumi K, Minami A (2008) The effect of anti-resorptive therapies on bone graft healing in an ovariectomized rat spinal arthrodesis model. Bone 43:1057–1066
Urrutia J, Briceno J, Carmona M, Olavarria F, Hodgson F (2010) Effect of a single dose of pamidronate administered at the time of surgery in a rabbit posterolateral spinal fusion model. Eur Spine J 19:940–944
Bransford R, Goergens E, Briody J, Amanat N, Cree A, Little D (2007) Effect of zoledronic acid in an L6–L7 rabbit spine fusion model. Eur Spine J 16:557–562
Huang RC, Khan SN, Sandhu HS et al (2005) Alendronate inhibits spine fusion in a rat model. Spine (Phila Pa 1976) 30:2516–2522
Babat LB, McLain R, Milks R, Ferrara L, Sohn MJ (2005) The effects of the antiresorptive agents calcitonin and pamidronate on spine fusion in a rabbit model. Spine J 5:542–547
Xue Q, Li H, Zou X et al (2005) The influence of alendronate treatment and bone graft volume on posterior lateral spine fusion in a porcine model. Spine 30:1116–1121
Xue Q, Li H, Zou X et al (2005) Healing properties of allograft from alendronate-treated animal in lumbar spine interbody cage fusion. Eur Spine J 14:222–226
Lehman RA Jr, Kuklo TR, Freedman BA, Cowart JR, Mense MG, Riew KD (2004) The effect of alendronate sodium on spinal fusion: a rabbit model. Spine J 4:36–43
Ohtori S, Inoue G, Orita S et al (2013) Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine (Phila Pa 1976) 38:E487–E492
Ohtori S, Inoue G, Orita S et al (2012) Teriparatide accelerates lumbar posterolateral fusion in women with postmenopausal osteoporosis: prospective study. Spine (Phila Pa 1976) 37:E1464–E1468
Ming N, Cheng JT, Rui YF et al (2012) Dose-dependent enhancement of spinal fusion in rats with teriparatide (PTH[1-34]). Spine (Phila Pa 1976) 37:1275–1282
Lehman RA Jr, Dmitriev AE, Cardoso MJ et al (2010) Effect of teriparatide [rhPTH(1,34)] and calcitonin on intertransverse process fusion in a rabbit model. Spine (Phila Pa 1976) 35:146–152
Ha Y, Maruo K, Racine L et al (2013) Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae. J Neurosurg Spine 19:360–369
Cahill PJ, Wang W, Asghar J et al (2012) The use of a transition rod may prevent proximal junctional kyphosis in the thoracic spine after scoliosis surgery: a finite element analysis. Spine (Phila Pa 1976) 37:E687–E695
Anand N, Rosemann R, Khalsa B, Baron EM (2010) Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis. Neurosurg Focus 28:E6
Anand N, Baron EM, Khandehroo B, Kahwaty S (2013) Long-term 2- to 5-year clinical and functional outcomes of minimally invasive surgery for adult scoliosis. Spine (Phila Pa 1976) 38:1566–1575
Hart R, McCarthy I, O’Brien M et al (2013) Identification of decision criteria for revision surgery among patients with proximal junctional failure following surgical treatment for spinal deformity. Spine (Phila Pa 1976) 38:E1223–E1227
McClendon J Jr, O’Shaughnessy BA, Sugrue PA et al (2012) Techniques for operative correction of proximal junctional kyphosis of the upper thoracic spine. Spine (Phila Pa 1976) 37:292–303
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Cho, S.K., Shin, J.I. & Kim, Y.J. Proximal junctional kyphosis following adult spinal deformity surgery. Eur Spine J 23, 2726–2736 (2014). https://doi.org/10.1007/s00586-014-3531-4
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DOI: https://doi.org/10.1007/s00586-014-3531-4