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Characteristics and risk factors for proximal junctional kyphosis in adult spinal deformity after correction surgery: a systematic review and meta-analysis

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Abstract

There are still controversies on characteristics and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients. The objective of this study is to explore the characteristics and risk factors for PJK in ASD. A systematic online search in databases including PubMed, EMBASE, Web of Science, and the Cochrane Library was performed to identify eligible studies. OR and weight mean difference with 95% CI were used to evaluate characteristics and risk factors. A total of 31 studies were finally included. ASD patients with PJK had larger proximal junctional angle (PJA), thoracic kyphosis (TK), pelvic incidence minus lumbar lordosis (PI-LL), and sagittal alignment. Age, female gender, and low BMD/osteoporosis were demographic risk factors for PJK. Using hooks at upper instrumented vertebra (UIV) and the selection of UIV above T8 could reduce the occurrence of PJK, while pelvic fixation was significantly associated with increased occurrence of PJK. Preoperative LL, preoperative pelvic tilt (PT), preoperative LL-TK, preoperative PI-LL, preoperative sagittal vertical axis (SVA), preoperative global spine alignment (GSA), postoperative PJA, change in PJA, postoperative TK, change in LL, change in SVA, and postoperative GSA were identified as risk factors for PJK. In conclusion, PJK patients had larger PJA, larger TK, smaller PI-LL, and larger sagittal alignment. Older female ASD patients with low BMD/osteoporosis are more likely to suffer from PJK. We recommend the following: (1) using hooks at UIV; (2) UIV should be chosen above T8, and pelvic fixation should be avoided if possible; (3) ideal correction of sagittal alignment should be performed to prevent the occurrence of PJK.

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References

  1. Grabel ZJ, Hart RA, Clark AP, Park SH, Shaffrey CI, Scheer JK, Smith JS, Kelly MP, DePasse JM, Gupta MC, Ames CP, Daniels AH (2018) Adult spinal deformity knowledge in orthopedic spine surgeons: impact of fellowship training, experience, and practice characteristics. Spine Deform 6:60–66. https://doi.org/10.1016/j.jspd.2017.06.003

    Article  PubMed  Google Scholar 

  2. Lee NJ, Kothari P, Kim JS, Shin JI, Phan K, Di Capua J, Somani S, Leven DM, Guzman JZ, Cho SK (2017) Early complications and outcomes in adult spinal deformity surgery: an NSQIP study based on 5803 patients. Global Spine J 7:432–440. https://doi.org/10.1177/2192568217699384

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yan P, Bao H, Qiu Y, Bao M, Varghese JJ, Sun X, Liu Z, Zhu Z, Qian B, Zheng M, Zhu F (2017) Mismatch between proximal rod contouring and proximal junctional angle: a predisposed risk factor for proximal junctional kyphosis in degenerative scoliosis. Spine 42:E280–e287. https://doi.org/10.1097/brs.0000000000001883

    Article  PubMed  Google Scholar 

  4. Cho SK, Shin JI, Kim YJ (2014) Proximal junctional kyphosis following adult spinal deformity surgery. Eur Spine J 23:2726–2736. https://doi.org/10.1007/s00586-014-3531-4

    Article  PubMed  Google Scholar 

  5. Liu FY, Wang T, Yang SD, Wang H, Yang DL, Ding WY (2016) Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J 25:2376–2383. https://doi.org/10.1007/s00586-016-4534-0

    Article  PubMed  Google Scholar 

  6. Raman T, Miller E, Martin CT, Kebaish KM (2017) The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study. Spine J 17:1489–1498. https://doi.org/10.1016/j.spinee.2017.05.017

    Article  PubMed  Google Scholar 

  7. McClendon J Jr, Smith TR, Sugrue PA, Thompson SE, O'Shaughnessy BA, Koski TR (2016) Spinal implant density and postoperative lumbar lordosis as predictors for the development of proximal junctional kyphosis in adult spinal deformity. World Neurosurg 95:419–424. https://doi.org/10.1016/j.wneu.2016.08.008

    Article  PubMed  Google Scholar 

  8. Wang H, Ma L, Yang D, Wang T, Yang S, Wang Y, Wang Q, Zhang F, Ding W (2016) Incidence and risk factors for the progression of proximal junctional kyphosis in degenerative lumbar scoliosis following long instrumented posterior spinal fusion. Medicine 95:e4443. https://doi.org/10.1097/md.0000000000004443

    Article  PubMed  PubMed Central  Google Scholar 

  9. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605. https://doi.org/10.1007/s10654-010-9491-z

    Article  PubMed  Google Scholar 

  10. Hyun SJ, Kim YJ, Rhim SC (2016) Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area. Spine J 16:1095–1101. https://doi.org/10.1016/j.spinee.2016.05.008

    Article  PubMed  Google Scholar 

  11. Kim HJ, Bridwell KH, Lenke LG, Park MS, Song KS, Piyaskulkaew C, Chuntarapas T (2014) Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine 39:E576–E580. https://doi.org/10.1097/brs.0000000000000246

    Article  PubMed  Google Scholar 

  12. Lee JH, Kim JU, Jang JS, Lee SH (2014) Analysis of the incidence and risk factors for the progression of proximal junctional kyphosis following surgical treatment for lumbar degenerative kyphosis: minimum 2-year follow-up. Br J Neurosurg 28:252–258. https://doi.org/10.3109/02688697.2013.835369

    Article  PubMed  Google Scholar 

  13. Martin CT, Skolasky RL, Mohamed AS, Kebaish KM (2013) Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine. Spine Deform 1:132–138. https://doi.org/10.1016/j.jspd.2013.01.005

    Article  PubMed  Google Scholar 

  14. Bridwell KH, Lenke LG, Cho SK, Pahys JM, Zebala LP, Dorward IG, Cho W, Baldus C, Hill BW, Kang MM (2013) Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery 72:899–906. https://doi.org/10.1227/NEU.0b013e31828bacd8

    Article  PubMed  Google Scholar 

  15. Kim HJ, Bridwell KH, Lenke LG, Park MS, Ahmad A, Song KS, Piyaskulkaew C, Hershman S, Fogelson J, Mesfin A (2013) Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine 38:896–901. https://doi.org/10.1097/BRS.0b013e3182815b42

    Article  PubMed  Google Scholar 

  16. 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 37:1479–1489. https://doi.org/10.1097/BRS.0b013e31824e4888

    Article  PubMed  Google Scholar 

  17. 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 36:E60–E68. https://doi.org/10.1097/BRS.0b013e3181eeaee2

    Article  PubMed  Google Scholar 

  18. Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine 30:1643–1649

    Article  PubMed  Google Scholar 

  19. Maruo K, Ha Y, Inoue S, Samuel S, Okada E, Hu SS, Deviren V, Burch S, William S, Ames CP, Mummaneni PV, Chou D, Berven SH (2013) Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity. Spine 38:E1469–E1476. https://doi.org/10.1097/BRS.0b013e3182a51d43

    Article  PubMed  Google Scholar 

  20. 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 33:2179–2184. https://doi.org/10.1097/BRS.0b013e31817c0428

    Article  PubMed  Google Scholar 

  21. Cho KJ, Suk SI, Park SR, Kim JH, Jung JH (2013) Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 22:394–401. https://doi.org/10.1007/s00586-012-2527-1

    Article  PubMed  Google Scholar 

  22. Mendoza-Lattes S, Ries Z, Gao Y, Weinstein SL (2011) Proximal junctional kyphosis in adult reconstructive spine surgery results from incomplete restoration of the lumbar lordosis relative to the magnitude of the thoracic kyphosis. Iowa Orthop J 31:199–206

    PubMed  PubMed Central  Google Scholar 

  23. Sebaaly A, Riouallon G, Obeid I, Grobost P, Rizkallah M, Laouissat F, Charles YP, Roussouly P (2017) Proximal junctional kyphosis in adult scoliosis: comparison of four radiological predictor models. Eur Spine J 27:613–621. https://doi.org/10.1007/s00586-017-5172-x

    Article  PubMed  Google Scholar 

  24. Sun XY, Zhang XN, Hai Y (2017) Optimum pelvic incidence minus lumbar lordosis value after operation for patients with adult degenerative scoliosis. Spine J 17:983–989. https://doi.org/10.1016/j.spinee.2017.03.008

    Article  PubMed  Google Scholar 

  25. Yasuda T, Hasegawa T, Yamato Y, Kobayashi S, Togawa D, Oe S, Matsuyama Y (2017) Proximal junctional kyphosis in adult spinal deformity with long spinal fusion from T9/T10 to the ilium. J Spine Surg (Hong Kong) 3:204–211. https://doi.org/10.21037/jss.2017.06.04

    Article  Google Scholar 

  26. Passias PG, Horn SR, Jalai CM, Ramchandran S, Poorman GW, Kim HJ, Smith JS, Sciubba D, Soroceanu A, Ames CP, Hamilton DK, Eastlack R, Burton D, Gupta M, Bess S, Lafage V, Schwab F (2017) Cervical alignment changes in patients developing proximal junctional kyphosis following surgical correction of adult spinal deformity. Neurosurgery. https://doi.org/10.1093/neuros/nyx479

  27. Yagi M, Fujita N, Tsuji O, Nagoshi N, Asazuma T, Ishii K, Nakamura M, Matsumoto M, Watanabe K (2017) Low bone-mineral density is a significant risk for proximal junctional failure after surgical correction of adult spinal deformity: a propensity score-matched analysis. Spine 43:485–491. https://doi.org/10.1097/brs.0000000000002355

    Article  Google Scholar 

  28. Nicholls FH, Bae J, Theologis AA, Eksi MS, Ames CP, Berven SH, Burch S, Tay BK, Deviren V (2017) Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients. Spine 42:1693–1698. https://doi.org/10.1097/brs.0000000000002209

    Article  PubMed  Google Scholar 

  29. Lafage R, Line BG, Gupta S, Liabaud B, Schwab F, Smith JS, Gum JL, Ames CP, Hostin R, Mundis GM Jr, Kim HJ, Bess S, Klineberg E, Lafage V (2017) Orientation of the upper-most instrumented segment influences proximal junctional disease following adult spinal deformity surgery. Spine 42:1570–1577. https://doi.org/10.1097/brs.0000000000002191

    Article  PubMed  Google Scholar 

  30. Kim DK, Kim JY, Kim DY, Rhim SC, Yoon SH (2017) Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data. J Korean Neurosurg Soc 60:174–180. https://doi.org/10.3340/jkns.2016.0707.014

    Article  PubMed  PubMed Central  Google Scholar 

  31. Lafage R, Schwab F, Glassman S, Bess S, Harris B, Sheer J, Hart R, Line B, Henry J, Burton D, Kim H, Klineberg E, Ames C, Lafage V (2017) Age-adjusted alignment goals have the potential to reduce PJK. Spine 42:1275–1282. https://doi.org/10.1097/brs.0000000000002146

    Article  PubMed  Google Scholar 

  32. Lafage R, Bess S, Glassman S, Ames C, Burton D, Hart R, Kim HJ, Klineberg E, Henry J, Line B, Scheer J, Protopsaltis T, Schwab F, Lafage V (2017) Virtual modeling of postoperative alignment after adult spinal deformity surgery helps predict associations between compensatory spinopelvic alignment changes, overcorrection, and proximal junctional kyphosis. Spine 42:E1119–e1125. https://doi.org/10.1097/brs.0000000000002116

    Article  PubMed  Google Scholar 

  33. Protopsaltis T, Bronsard N, Soroceanu A, Henry JK, Lafage R, Smith J, Klineberg E, Mundis G, Kim HJ, Hostin R, Hart R, Shaffrey C, Bess S, Ames C (2017) Cervical sagittal deformity develops after PJK in adult thoracolumbar deformity correction: radiographic analysis utilizing a novel global sagittal angular parameter, the CTPA. Eur Spine J 26:1111–1120. https://doi.org/10.1007/s00586-016-4653-7

    Article  PubMed  Google Scholar 

  34. Scheer JK, Osorio JA, Smith JS, Schwab F, Lafage V, Hart RA, Bess S, Line B, Diebo BG, Protopsaltis TS, Jain A, Ailon T, Burton DC, Shaffrey CI, Klineberg E, Ames CP (2016) Development of validated computer-based preoperative predictive model for proximal junction failure (PJF) or clinically significant PJK with 86% accuracy based on 510 ASD patients with 2-year follow-up. Spine 41:E1328–e1335. https://doi.org/10.1097/brs.0000000000001598

    Article  PubMed  Google Scholar 

  35. Smith MW, Annis P, Lawrence BD, Daubs MD, Brodke DS (2015) Acute proximal junctional failure in patients with preoperative sagittal imbalance. Spine J 15:2142–2148. https://doi.org/10.1016/j.spinee.2015.05.028

    Article  PubMed  Google Scholar 

  36. Park SJ, Lee CS, Chung SS, Lee JY, Kang SS, Park SH (2017) Different risk factors of proximal junctional kyphosis and proximal junctional failure following long instrumented fusion to the sacrum for adult spinal deformity: survivorship analysis of 160 patients. Neurosurgery 80:279–286. https://doi.org/10.1227/neu.0000000000001240

    Article  PubMed  Google Scholar 

  37. Kim HJ, Iyer S (2016) Proximal junctional kyphosis. J Am Acad Orthop Surg 24:318–326. https://doi.org/10.5435/jaaos-d-14-00393

    Article  PubMed  Google Scholar 

  38. Glassman SD, Coseo MP, Carreon LY (2016) Sagittal balance is more than just alignment: why PJK remains an unresolved problem. Scoliosis Spinal Disord 11:1. https://doi.org/10.1186/s13013-016-0064-0

    Article  PubMed  PubMed Central  Google Scholar 

  39. Zhang L, Yin X, Wang J, Xu D, Wang Y, Yang J, Tao Y, Zhang S, Feng X, Yan C (2018) Associations between VDR gene polymorphisms and osteoporosis risk and bone mineral density in postmenopausal women: a systematic review and meta-analysis. Sci Rep 8:981. https://doi.org/10.1038/s41598-017-18670-7

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Hassanzadeh H, Gupta S, Jain A, El Dafrawy MH, Skolasky RL, Kebaish KM (2013) Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform 1:299–305. https://doi.org/10.1016/j.jspd.2013.05.008

    Article  PubMed  Google Scholar 

  41. Hart R, McCarthy I, O'Brien M, Bess S, Line B, Adjei OB, Burton D, Gupta M, Ames C, Deviren V, Kebaish K, Shaffrey C, Wood K, Hostin R (2013) Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity. Spine 38:E1223–E1227. https://doi.org/10.1097/BRS.0b013e31829fedde

    Article  PubMed  Google Scholar 

  42. Hostin R, McCarthy I, O'Brien M, Bess S, Line B, Boachie-Adjei O, Burton D, Gupta M, Ames C, Deviren V, Kebaish K, Shaffrey C, Wood K, Hart R (2013) Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity. Spine 38:1008–1015. https://doi.org/10.1097/BRS.0b013e318271319c

    Article  PubMed  Google Scholar 

  43. Barrey C, Roussouly P, Perrin G, Le Huec JC (2011) Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? Eur Spine J 20(Suppl 5):626–633. https://doi.org/10.1007/s00586-011-1930-3

    Article  PubMed  PubMed Central  Google Scholar 

  44. Yang C, Yang M, Wei X, Shao J, Chen Y, Zhao J, Zhu X, He D, Li M (2016) Lumbar lordosis minus thoracic kyphosis: a novel regional predictor for sagittal balance in elderly populations. Spine 41:399–403. https://doi.org/10.1097/brs.0000000000001231

    Article  PubMed  Google Scholar 

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  1. Department of Orthopaedic Surgery, Jingzhou Central Hospital, 60 Jingzhong Road, Jingzhou City, 434020, Hubei Province, China

    Lixue Zou, Jun Liu & Hougen Lu

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  1. Lixue Zou
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  2. Jun Liu
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Zou, L., Liu, J. & Lu, H. Characteristics and risk factors for proximal junctional kyphosis in adult spinal deformity after correction surgery: a systematic review and meta-analysis. Neurosurg Rev 42, 671–682 (2019). https://doi.org/10.1007/s10143-018-1004-7

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