Opposed to proximal junctional kyphosis and proximal junctional failure, their distal equivalents, distal junctional kyphosis and failure (DJK/DJF) have received less attention in the literature. The aim of this article is to provide an overview of the problem of DJK–DJF in different clinical scenarios such as adolescent idiopathic scoliosis (AIS), Scheuermann’s kyphosis (SK) and adult deformity surgery and to suggest a strategy for prevention and treatment.
A narrative review of the literature was conducted to identify the best evidence on the risk factors of the problem.
DJK/DJF have been described as a complication of AIS, SK and adult spine deformity (ASD). For AIS and SK, the choice of a lower instrumented vertebra more cranial than the sagittal stable vertebra has shown to increase the incidence of DJK and DJF. For ASD, constructs ending with S1 pedicle screws had a higher incidence of DJK/DJF than those ending distally with S1 pedicle plus iliac screws.
The proposed strategy of treatment includes restoration of normal sagittal alignment, choice of a distal fixation point stable in the sagittal, coronal and transverse planes, balancing the fusion mass over the distal fixation point and providing solid fixation at the distal end of the construct.
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Zanirato A, Damilano M, Formica M et al (2018) Complications in adult spine deformity surgery: a systematic review of the recent literature with reporting of aggregated incidences. Eur Spine J 27(9):2272–2284
Lowe TG, Lenke L, Betz R, Newton P, Clements D, Haher T, Crawford A, Letko L, Wilson LA (2006) Distal junctional kyphosis of adolescent idiopathic thoracic curves following anterior or posterior instrumented fusion: incidence, risk factors, and prevention. Spine 31(3):299–302
Ascani E, Rosa G (1994) Scheuermann kyphosis. In: Weinstein SL (ed) The pediatric spine: principles and practice. Raven Press, New York, pp 557–584
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 34(20):E729–E734. https://doi.org/10.1097/brs.0b013e3181ae2ab2
Cho KJ, Lenke LG, Bridwell KH, Kamiya M, Sides B (2009) Selection of the optimal distal fusion level in posterior instrumentation and fusion for thoracic hyperkyphosis: the sagittal stable vertebra concept. Spine 34(8):765–770. https://doi.org/10.1097/brs.0b013e31819e28ed
Yanik HS, Ketenci IE, Coskun T, Ulusoy A, Erdem S (2016) Selection of distal fusion level in posterior instrumentation and fusion of Scheuermann kyphosis: is fusion to sagittal stable vertebra necessary? Eur Spine J 25(2):583–589. https://doi.org/10.1007/s00586-015-4123-7
Gong Y, Yuan L, He M, Yu M, Zeng Y, Liu X, Chen Z (2019) Comparison between stable sagittal vertebra and first lordotic vertebra instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: systematic review and meta-analysis. Clin Spine Surg. https://doi.org/10.1097/bsd.0000000000000792
Zhu W, Sun X, Pan W, Yan H, Liu Z, Qiu Y, Zhu Z (2019) Curve patterns deserve attention when determining the optimal distal fusion level in correction surgery for Scheuermann kyphosis. Spine J 19(9):1529–1539. https://doi.org/10.1016/j.spinee.2019.04.007
Ghasemi A, Stubig T, Nasto LA, Ahmed M, Mehdian H (2017) Distal junctional kyphosis in patients with Scheuermann’s disease: a retrospective radiographic analysis. Eur Spine J 26(3):913–920. https://doi.org/10.1007/s00586-016-4924-3
Lonner BS, Parent S, Shah SA, Sponseller P, Yaszay B, Samdani AF, Cahill PJ, Pahys JM, Betz R, Ren Y, Shufflebarger HL, Newton PO (2018) Reciprocal changes in sagittal alignment with operative treatment of adolescent Scheuermann kyphosis-prospective evaluation of 96 patients. Spine Deform 6(2):177–184. https://doi.org/10.1016/j.jspd.2017.07.001
Ameri E, Behtash H, Mobini B, Ghandhari H, Vahid Tari H, Khakinahad M (2011) The prevalence of distal junctional kyphosis following posterior instrumentation and arthrodesis for adolescent idiopathic scoliosis. Acta Med Iran 49(6):357–363
Floccari LV, Su AW, McIntosh AL, Rathjen K, Shaughnessy WJ, Larson AN (2019) Distal junctional failure following pediatric spinal fusion. J Pediatr Orthop 39(4):202–208. https://doi.org/10.1097/BPO.0000000000000898
Fischer CR, Lenke LG, Bridwell KH, Boachie-Adjei O, Gupta M, Kim YJ (2018) Optimal lowest instrumented vertebra for thoracic adolescent idiopathic scoliosis. Spine Deform 6(3):250–256. https://doi.org/10.1016/j.jspd.2017.10.002
Yang J, Andras LM, Broom AM, Gonsalves NR, Barrett KK, Georgiadis AG, Flynn JM, Tolo VT, Skaggs DL (2018) Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis. Spine Deform 6(1):38–42. https://doi.org/10.1016/j.jspd.2017.06.007
Edwards CC II, Bridwell KH, Patel A, Rinella AS, Kim YJ, Berra A, Della Rocca GJ, Lenke LG (2003) Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc. Spine 28(18):2122–2131
Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, Edwards C II, Baldus C (2007) Thoracolumbar deformity arthrodesis stopping at L5. Fate of the L5-S1 disc, minimum 5-year follow-up. Spine 32(24):2771–2776
Cho KJ, Suk SI, Park SR, Kim JH, Kang SB, Kim HS, Oh SJ (2010) Risk factors of sagittal decompensation after long posterior instrumentation and fusion for degenerative lumbar scoliosis. Spine 35(17):1595–1601. https://doi.org/10.1097/BRS.0b013e3181bdad89
Yasuda T, Hasegawa T, Yamato Y, Kobayashi S, Togawa D, Banno T, Arima H, Oe S, Matsuyama Y (2016) Lumbosacral junctional failures after long spinal fusion for adult spinal deformity-which vertebra is the preferred distal instrumented vertebra? Spine Deform 4(5):378–384. https://doi.org/10.1016/j.jspd.2016.03.001
Passias PG, Klineberg EO, Jalai CM, Worley N, Poorman GW, Line B, Oh C, Burton DC, Kim HJ, Sciubba DM, Hamilton DK, Ames CP, Smith JS, Shaffrey CI, Lafage V, Bess S, International Spine Study Group (2016) Hospital readmission within 2 years following adult thoracolumbar spinal deformity surgery: Prevalence, predictors, and effect on patient-derived outcome measures. Spine 41(17):1355–1364. https://doi.org/10.1097/BRS.0000000000001552
Passias PG, Vasquez-Montes D, Poorman GW, Protopsaltis T, Horn SR, Bortz CA, Segreto F, Diebo B, Ames C, Smith J, LaFage V, LaFage R, Klineberg E, Shaffrey C, Bess S, Schwab F, ISSG (2018) Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J 18(12):2187–2194. https://doi.org/10.1016/j.spinee.2018.04.017
Langella F, Villafañe JH, Ismael M, Buric J, Piazzola A, Lamartina C, Berjano P (2018) Reliability of the xipho-pubic angle in patients with sagittal imbalance of the spine. J Neurosurg Sci 62(2):121–127. https://doi.org/10.23736/S0390-5616.16.03556-6
Berjano P, Xu M, Damilano M, Scholl T, Lamartina C, Jekir M, Galbusera F (2019) Supplementary delta-rod configurations provide superior stiffness and reduced rod stress compared to traditional multiple-rod configurations after pedicle subtraction osteotomy: a finite element study. Eur Spine J. https://doi.org/10.1007/s00586-019-06012-2
Lamartina C, Berjano P (2014) Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms. Eur Spine J 23(6):1177–1189. https://doi.org/10.1007/s00586-014-3227-9
Berjano P, Cecchinato R, Damilano M et al (2013) Preoperative calculation of the necessary correction in sagittal imbalance surgery: validation of three predictive methods. Eur Spine J 22(6):847–852
Langella F, Villafañe JH, Damilano M, Cecchinato R, Pejrona M, Ismael M, Berjano P (2017) Predictive accuracy of surgimap surgical planning for sagittal imbalance: a cohort study. Spine 42(22):E1297–E1304. https://doi.org/10.1097/BRS.0000000000002230
Pérez-Grueso FS, Cecchinato R, Berjano P (2015) Ponte osteotomies in thoracic deformities. Eur Spine J 25:s38–s41
Ponte A, Orlando G, Siccardi GL (2018) The true ponte osteotomy: by the one who developed it. Spine Deform 6(1):2–11. https://doi.org/10.1016/j.jspd.2017.06.006
Berjano P, Aebi M (2015) Pedicle subtraction osteotomies (PSO) in the lumbar spine for sagittal deformities. Eur Spine J 24(Suppl 1):S49–S57. https://doi.org/10.1007/s00586-014-3670-7
Berjano P, Pejrona M, Damilano M, Cecchinato R, Aguirre MF, Lamartina C (2015) Corner osteotomy: a modified pedicle subtraction osteotomy for increased sagittal correction in the lumbar spine. Eur Spine J 24(Suppl 1):58–65. https://doi.org/10.1007/s00586-014-3618-y
Cecchinato R, Redaelli A, Martini C et al (2016) Long fusions to S1 with or without pelvic fixation can induce relevant acute variations in pelvic incidence: a retrospective cohort study of adult spine deformity surgery. Eur Spine J 26(4):436–441
Fu KMG, Smith JS, Burton DC, Shaffrey CI, Boachie-Adjei O, Carlson B, Schwab FJ, Lafage V, Hostin R, Bess S, Akbarnia BA, Mundis G, Klineberg E, Gupta M, International Spine Study Group (2013) Outcomes and complications of extension of previous long fusion to the sacro-pelvis: is an anterior approach necessary? World Neurosurg 79(1):177–181
Hosseini P, Mundis GM Jr, Eastlack RK, Bagheri R, Vargas E, Tran S, Akbarnia BA (2017) Preliminary results of anterior lumbar interbody fusion, anterior column realignment for the treatment of sagittal malalignment. Neurosurg Focus 43(6):E6. https://doi.org/10.3171/2017.8.FOCUS17423
Crawford CH III, Bridwell KH, Cho W, Buchowski JM, O’Shaughnessy BA, Chang MS, Auerbach JD (2010) Extension of prior idiopathic scoliosis fusions to the sacrum a matched cohort analysis of sixty patients with minimum two-year follow-up. Spine 35:1843–1848
Graat HC, Schimmel JJ, Hoogendoorn RJ, van Hessem L, Hosman A, de Kleuver M (2016) Poor radiological and good functional long-term outcome of surgically treated Scheuermann patients. Spine 41(14):E869–E878. https://doi.org/10.1097/BRS.0000000000001402
Lamartina C, Berjano P, Petruzzi M, Sinigaglia A, Casero G, Cecchinato R, Damilano M, Bassani R (2012) Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesis. Eur Spine J 21(Suppl 1):S27–S31. https://doi.org/10.1007/s00586-012-2236-9
Berjano P, Cecchinato R, Sinigaglia A, Damilano M, Ismael MF, Martini C, Villafañe JH, Lamartina C (2015) Anterior column realignment from a lateral approach for the treatment of severe sagittal imbalance: a retrospective radiographic study. Eur Spine J 24(Suppl 3):433–438. https://doi.org/10.1007/s00586-015-3930-1
Conflict of interest
Pedro Berjano: Honorarium from Nuvasive, DePuySynthes, K2M, Medacta and royalties from Nuvasive. Marco Damilano: Honorarium fron Nuvasive. Matteo Pejrona: Nothing to disclose. Francesco Langella: Nothing to disclose. Claudio Lamartina: Honorarium from Nuvasive, DePuySynthes, K2M, Medacta and royalties from Nuvasive and Medacta.
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Berjano, P., Damilano, M., Pejrona, M. et al. Revision surgery in distal junctional kyphosis. Eur Spine J 29, 86–102 (2020). https://doi.org/10.1007/s00586-020-06304-y
- Distal junctional kyphosis
- Distal junctional failure
- Revision surgery