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European Spine Journal

, Volume 27, Supplement 1, pp 139–148 | Cite as

The mechanism in junctional failure of thoraco-lumbar fusions. Part II: Analysis of a series of PJK after thoraco-lumbar fusion to determine parameters allowing to predict the risk of junctional breakdown

  • Antonio A. Faundez
  • Jonathon Richards
  • Philippe Maxy
  • Rachel Price
  • Amélie Léglise
  • Jean-Charles Le Huec
Original Article

Abstract

Purpose

To identify risk factors, in 12 patients with junctional breakdown (JBD) after thoraco-sacral fusions and to test a software locating maximal bending moment on full spine EOS images.

Methods

Twelve patients underwent long fusions for lumbar degenerative pathologies. Preop EOS images were compared to first postop EOS showing JBD. Parameters analyzed were: spinopelvic parameters [pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), spinosacral angle (SSA), lordosis, and kyphosis], proximal junctional angle (PJA), odontoid-hip axis angle (ODHA), and CIA. A new software estimated the location of maximum bending moment (M max) before and after JBD.

Results

All patients except one had a JBD located between T10 and L1, diagnosed at average follow-up of 18.58 months. JBD was a fracture in six patients, severe adjacent disc degeneration in the remaining. Average PI was 52°. PT increased, SS decreased after JBD versus preop (p > 0.05). Average PJA was 34.5°. Global lordosis (GLL), upper lordosis (ULL), L4–S1 lordosis, and thoracic kyphosis (TK) were increased (p < 0.05). Lower lumbar lordosis (LLL), was not increased postJBD (p = 0.6). SVA, SSA, ODHA, and C7 slope were not modified (p > 0.05). CIA average value decreased by 7.5% after JBD. T1–T5 alignment was correlated to C7 slope before (R 2 = 0.77075) and after JBD (R 2 = 0.85409). ODHA decreased after JBD (p > 0.05). Most JBD occurred at or one level away from preoperative M max location.

Conclusion

This study confirms the importance of harmonious distribution of lumbar (GLL, ULL, and ILL) and thoracic curves (TK, T1–T5 segment) in thoraco-sacral fusions. All patients showed an exaggerated ULL, resulting in a posterior shift and increased lever arm at the thoraco-lumbar junction, leading to JBD.

Keywords

Proximal junctional kyphosis Proximal junctional failure Bending moment Vertebral fracture Sagittal balance 

Notes

Compliance with ethical standards

Conflict of interest

There is no conflict of interest.

References

  1. 1.
    Amabile C, Pillet H, Lafage V, Barrey C, Vital JM, Skalli W (2016) A new quasi-invariant parameter characterizing the postural alignment of young asymptomatic adults. Eur Spine J 25:3666–3674.  https://doi.org/10.1007/s00586-016-4552-y CrossRefPubMedGoogle Scholar
  2. 2.
    Amabile C, Le Huec JC, Skalli W (2016) Invariance of head-pelvis alignment and compensatory mechanisms for asymptomatic adults older than 49 years. Eur Spine J.  https://doi.org/10.1007/s00586-016-4830-8 Google Scholar
  3. 3.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Barrey C, Roussouly P, Le Huec JC, D’Acunzi G, Perrin G (2013) Compensatory mechanisms contributing to keep the sagittal balance of the spine. Eur Spine J 22(Suppl 6):S834–S841.  https://doi.org/10.1007/s00586-013-3030-z CrossRefPubMedGoogle Scholar
  5. 5.
    Le Huec JC, Charosky S, Barrey C, Rigal J, Aunoble S (2011) Sagittal imbalance cascade for simple degenerative spine and consequences: algorithm of decision for appropriate treatment. Eur Spine J 20(Suppl 5):699–703.  https://doi.org/10.1007/s00586-011-1938-8 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Le Huec JC, Faundez A, Dominguez D, Hoffmeyer P, Aunoble S (2015) Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review. Int Orthop 39:87–95.  https://doi.org/10.1007/s00264-014-2516-6 CrossRefPubMedGoogle Scholar
  7. 7.
    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 CrossRefPubMedGoogle Scholar
  8. 8.
    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 CrossRefPubMedGoogle Scholar
  9. 9.
    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.  https://doi.org/10.1097/brs.0000000000000222 CrossRefGoogle Scholar
  10. 10.
    Denis F, Sun EC, Winter RB (2009) Incidence and risk factors for proximal and distal junctional kyphosis following surgical treatment for Scheuermann kyphosis: minimum five-year follow-up. Spine (Phila Pa 1976) 34:E729–E734.  https://doi.org/10.1097/brs.0b013e3181ae2ab2 CrossRefGoogle Scholar
  11. 11.
    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 (Phila Pa 1976) 30:1643–1649CrossRefGoogle Scholar
  12. 12.
    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 CrossRefPubMedGoogle Scholar
  13. 13.
    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 (Phila Pa 1976) 39:E576–E580.  https://doi.org/10.1097/brs.0000000000000246 CrossRefGoogle Scholar
  14. 14.
    Kim HJ, Yagi M, Nyugen J, Cunningham ME, Boachie-Adjei O (2012) Combined anterior-posterior surgery is the most important risk factor for developing proximal junctional kyphosis in idiopathic scoliosis. Clin Orthop Relat Res 470:1633–1639.  https://doi.org/10.1007/s11999-011-2179-1 CrossRefPubMedGoogle Scholar
  15. 15.
    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.  https://doi.org/10.1097/brs.0b013e31817c0428 CrossRefGoogle Scholar
  16. 16.
    Kim YJ, Bridwell KH, Lenke LG, Kim J, Cho SK (2005) Proximal junctional kyphosis in adolescent idiopathic scoliosis following segmental posterior spinal instrumentation and fusion: minimum 5-year follow-up. Spine (Phila Pa 1976) 30:2045–2050CrossRefGoogle Scholar
  17. 17.
    Kim YJ, Lenke LG, Bridwell KH, Kim J, Cho SK, Cheh G, Yoon J (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.  https://doi.org/10.1097/brs.0b013e31815a7ead CrossRefGoogle Scholar
  18. 18.
    Lau D, Clark AJ, Scheer JK, Daubs MD, Coe JD, Paonessa KJ, LaGrone MO, Kasten MD, Amaral RA, Trobisch PD, Lee JH, Fabris-Monterumici D, Anand N, Cree AK, Hart RA, Hey LA, Ames CP, Committee SRSASD (2014) Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976) 39:2093–2102.  https://doi.org/10.1097/brs.0000000000000627 CrossRefGoogle Scholar
  19. 19.
    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 CrossRefPubMedGoogle Scholar
  20. 20.
    Lonner BS, Newton P, Betz R, Scharf C, O’Brien M, Sponseller P, Lenke L, Crawford A, Lowe T, Letko L, Harms J, Shufflebarger H (2007) Operative management of Scheuermann’s kyphosis in 78 patients: radiographic outcomes, complications, and technique. Spine (Phila Pa 1976) 32:2644–2652.  https://doi.org/10.1097/brs.0b013e31815a5238 CrossRefGoogle Scholar
  21. 21.
    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 (Phila Pa 1976) 38:E1469–E1476.  https://doi.org/10.1097/brs.0b013e3182a51d43 CrossRefGoogle Scholar
  22. 22.
    McClendon J Jr, O’Shaughnessy BA, Sugrue PA, Neal CJ, Acosta FL Jr, Koski TR, Ondra SL (2012) Techniques for operative correction of proximal junctional kyphosis of the upper thoracic spine. Spine (Phila Pa 1976) 37:292–303.  https://doi.org/10.1097/brs.0b013e318222dc8a CrossRefGoogle Scholar
  23. 23.
    Nguyen NL, Kong CY, Hart RA (2016) Proximal junctional kyphosis and failure-diagnosis, prevention, and treatment. Curr Rev Musculoskelet Med 9:299–308.  https://doi.org/10.1007/s12178-016-9353-8 CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Wang J, Zhao Y, Shen B, Wang C, Li M (2010) Risk factor analysis of proximal junctional kyphosis after posterior fusion in patients with idiopathic scoliosis. Injury 41:415–420.  https://doi.org/10.1016/j.injury.2010.01.001 CrossRefPubMedGoogle Scholar
  25. 25.
    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.  https://doi.org/10.1097/brs.0b013e3181eeaee2 CrossRefGoogle Scholar
  26. 26.
    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.  https://doi.org/10.1097/brs.0b013e31824e4888 CrossRefGoogle Scholar
  27. 27.
    Yanik HS, Ketenci IE, Polat A, Ulusoy A, Deniz G, Kose O, Erdem S (2015) Prevention of proximal junctional kyphosis after posterior surgery of Scheuermann kyphosis: an operative technique. J Spinal Disord Tech 28:E101–E105.  https://doi.org/10.1097/BSD.0000000000000157 CrossRefPubMedGoogle Scholar
  28. 28.
    Faro FD, Marks MC, Pawelek J, Newton PO (2004) Evaluation of a functional position for lateral radiograph acquisition in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 29:2284–2289CrossRefGoogle Scholar
  29. 29.
    Vaz G, Roussouly P, Berthonnaud E, Dimnet J (2002) Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 11:80–87CrossRefPubMedGoogle Scholar
  30. 30.
    Meeh C (1895) Volummessungen des menschlichen Körpers und seiner einzelner Teile in der verschiedenen Altersstufen. Ztschr fur Biologie 13:125–147Google Scholar
  31. 31.
    Le Huec JC, Demezon H, Aunoble S (2015) Sagittal parameters of global cervical balance using EOS imaging: normative values from a prospective cohort of asymptomatic volunteers. Eur Spine J 24:63–71.  https://doi.org/10.1007/s00586-014-3632-0 CrossRefPubMedGoogle Scholar
  32. 32.
    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976) 30:346–353CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Antonio A. Faundez
    • 1
  • Jonathon Richards
    • 2
  • Philippe Maxy
    • 3
  • Rachel Price
    • 2
  • Amélie Léglise
    • 2
  • Jean-Charles Le Huec
    • 2
  1. 1.Orthopaedic Surgery and Traumatology DivisionGeneva University Hospitals and Hôpital La TourMeyrinSwitzerland
  2. 2.Spine Unit 2University Victor SegalenBordeauxFrance
  3. 3.FASTER FoundationCarougeSwitzerland

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