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Proximal junctional kyphosis is a rebalancing spinal phenomenon due to insufficient postoperative thoracic kyphosis after adolescent idiopathic scoliosis surgery

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Abstract

Purpose

Many authors tried to explain proximal junctional kyphosis (PJK) after adolescent idiopathic scoliosis (AIS) surgery by looking for risk factors. Latest publications focus on sagittal alignment. Each healthy adolescent has a specific thoracic kyphosis (TK) depending on their pelvic parameters and lumbar lordosis (LL). The objective of this work is to determine if the difference between TK at follow-up (TKFU) and the patient-specific TK (PSTK) plays a role in PJK occurrence after AIS surgery. The secondary objective was to find other risk factors.

Methods

We analyzed retrospectively 570 thoracic AIS who underwent a posterior thoracic fusion from nine centers. The series was separated in two groups: with and without PJK. PSTK was calculated with the formula PSTK = 2(PT + LL-PI). TK Gap was the difference between TKFU and PSTK. Logistic regression was utilized to test the impact of TK Gap and other known risk factors on PJK occurrence.

Results

Univariate analysis showed 15 factors significantly different between the groups. In a multivariate analysis, three factors had a strong significant influence on PJK: TKFU, TK Gain and TK Gap. Four additional factors affected the rate of PJK: Posterior translation on two rods, preoperative TK, preoperative LL and number of instrumented vertebrae.

Conclusion

PJK is related to the insufficient TK at follow-up, compared to the specific TK that every patient should have according to their pelvic parameters. PJK incidence is significantly reduced by a strong gain in TK and a thoracic selective fusion which leaves the proximal lumbar vertebrae free.

Level of evidence I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding

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Acknowledgements

This work has been carried out under the patronage of the French Study Group of Scoliosis (GES) from the French Society of Spine Surgery (SFCR); one of the authors (FS) performed this research in the framework of the International PhD in Innovation Sciences and Technologies at the University of Cagliari, Italy.

Funding

Jean-Luc Clément received consultancy fees and royalties from Médicrea International. Brice Ilharreborde received consultancy fees from Zimmer Biomet, Implanet and Medtronic. Yann-Philippe Charles received grants and royalties from Stryker and Clairance. Marc Szadkowski received consultancy fees and royalties from Clairance and consultancy fees from Zimmer. Louis Boissiere received consultant fees from Neo and Spineart. Federico Solla received financial support for attending symposia from Médicrea International, Euros, and Zimmer.

Author information

Authors and Affiliations

  1. Department of Pediatric Orthopedics and Scoliosis Surgery, Hôpitaux Pédiatriques de Nice Chu Lenval, 57 Avenue de la Californie, 06200, Nice, France

    Jean-Luc Clément & Federico Solla

  2. Pediatric Orthopedics, Hôpital Timone Enfants, Aix Marseille Université, 264 rue Saint Pierre, 13005, Marseille, France

    Sebastien Pesenti

  3. Department of Pediatric Orthopedics, CHU Robert Debré, AP-HP, University of Paris, 48 Bd Sérurier, 75019, Paris, France

    Brice Ilharreborde

  4. Department of Pediatric Orthopedics, Institut Calot, rue du Dr Calot, 62600, Berck sur mer, France

    Christian Morin

  5. Department of Spine Surgery, Fédération de Médecine Translationnelle (FMTS), Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France

    Yann-Philippe Charles

  6. Spine Center, 6 rue de Belliniere, 49800, Trelaze, France

    Henri-François Parent

  7. Department of Pediatric Surgery, Hôpital Sud, CHU de Rennes, 16 Boulevard de Bulgarie, 35200, Rennes, France

    Philippe Violas

  8. Santy Orthopedic Center, 24 avenue Paul Santy, 69008, Lyon, France

    Marc Szadkowski

  9. Department of Orthopaedic Surgery, Spine Unit, CHU Bordeaux Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, France

    Louis Boissière

Authors
  1. Jean-Luc Clément
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  2. Sebastien Pesenti
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  3. Brice Ilharreborde
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  4. Christian Morin
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  5. Yann-Philippe Charles
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  7. Philippe Violas
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  8. Marc Szadkowski
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  9. Louis Boissière
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  10. Federico Solla
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Contributions

All authors contributed to the study conception, design, and follow-up of the patients. Material preparation, data collection and analysis were performed by JLC and SP. The statistical analysis was performed by FS. The first draft of the manuscript was written by JLC, the final manuscript by JLC, FS and SP. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jean-Luc Clément.

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Conflict of interest

All procedures were in accordance with the ethical standards of the authors’ Institutional Review Board (CPP: Committee for the Protection of Persons; n°2017728v0) and with the 1964 Helsinki declaration and its later amendments. The authors declare that they have no competing interests related to this work.

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Clément, JL., Pesenti, S., Ilharreborde, B. et al. Proximal junctional kyphosis is a rebalancing spinal phenomenon due to insufficient postoperative thoracic kyphosis after adolescent idiopathic scoliosis surgery. Eur Spine J 30, 1988–1997 (2021). https://doi.org/10.1007/s00586-021-06875-4

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  • DOI: https://doi.org/10.1007/s00586-021-06875-4

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