Abstract
Background
Several studies have identified risk factors for proximal junctional kyphosis (PJK) after instrumentation for scoliosis, but the relative risks are unclear.
Questions/purposes
We identified risk factors for PJK in idiopathic scoliosis and determined their relative risks in a predictive model.
Methods
We retrospectively reviewed the charts of all 249 patients with idiopathic scoliosis who underwent surgery from 1996 to 2008. We compared those who developed PJK to those who did not. We identified risk factors for PJK and performed univariate and multivariate analyses to determine independent risk factors. We then used a Cox proportional-hazards model to evaluate the time to the development of PJK. The minimum followup time was 1.5 years (mean, 4 years; range, 1.5–9 years).
Results
The incidence of PJK in our series of patients with idiopathic scoliosis was 17%. There was no difference in Scoliosis Research Society-22 scores between patients without and with junctional kyphosis. Independent risk factors included proximal fusion to T1 through T3 and sagittal sacral vertical line, while in the Cox model a combined anterior-posterior approach surgery was the most important risk factor.
Conclusions
Patients with a T1 through T3 upper instrumented level, combined anterior-posterior surgery, and increased sagittal sacral vertical line difference had a higher likelihood of developing PJK. Of these risk factors, anterior-posterior surgery was the strongest risk factor.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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References
Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the Scoliosis Research Society-22 patient questionnaire for idiopathic scoliosis. (Spine Phila Pa 1976). 2003;28:63–69.
Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976). 2005;30:1643–1649.
Helgeson MD, Shah SA, Newton PO, Clements DH 3rd, Betz RR, Marks MC, Bastrom T; Harms Study Group. Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation. Spine (Phila Pa 1976). 2010;35:177–181.
Hollenbeck SM, Glattes RC, Asher MA, Lai SM, Burton DC. The prevalence of increased proximal junctional flexion following posterior instrumentation and arthrodesis for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33:1675–1681.
Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G. Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976). 2008;30:2179–2184.
Kim YJ, Bridwell KH, Lenke LG, Kim J, Cho SK. Proximal junctional kyphosis in adolescent idiopathic scoliosis following segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976). 2005;30:2045–2050.
Kim YJ, Lenke LG, Bridwell KH, Kim J, Cho SK, Cheh G, Yoon J. Proximal junctional kyphosis in adolescent idiopathic scoliosis after three different types of posterior segmental spinal instrumentation and fusions: incidence and risk factor analysis of 410 cases. Spine (Phila Pa 1976). 2007;32:2731–2738.
Lee GA, Betz RR, Clements DH 3rd, Huss GK. Proximal kyphosis after posterior spinal fusion in patients with idiopathic scoliosis. Spine (Phila Pa 1976). 1999;24:795–799.
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. Operative management of Scheuermann’s kyphosis in 78 patients: radiographic outcomes, complications, and technique. Spine (Phila Pa 1976). 2007;32:2644–2652.
Sacramento-Dominguez C, Vayas-Diez R, Coll-Mesa L, Parrilla AP, Machado-Calvo M, Pinilla JA, Sosa AJ, Lopez Gde L. 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). 2009;34:2787–2791.
Wang J, Zhao Y, Shen B, Wang C, Li M. Risk factor analysis of proximal junctional kyphosis after posterior fusion in patients with idiopathic scoliosis. Injury. 2010;41:415–420.
Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36:E60–8.
Yang SH, Chen PQ. Proximal kyphosis after short posterior fusion for thoracolumbar scoliosis. Clin Orthop Relat Res. 2003;411:152–158.
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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
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Kim, H.J., Yagi, M., Nyugen, J. et al. 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 (2012). https://doi.org/10.1007/s11999-011-2179-1
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DOI: https://doi.org/10.1007/s11999-011-2179-1