An Effective and Safe Surgical Technique for Salvage of Postoperative Proximal Junctional Failure in Pediatric Patients-A Case Series

Abstract

Background: Proximal junctional failure (PJF) is a known complication following posterior spinal instrumentation surgery and can be defined simply as proximal junctional kyphosis that requires surgical revision of the proximal instrumentation. PJF can be associated with pain, decreased neurologic function, infection, and increased morbidity. There is little literature on this topic in children and especially on specific surgical techniques for revision surgery.Methods: The revision technique involves extending the spine instrumentation proximally with paired sets of sublaminar bands used as anchors. Posterior osteotomies are typically required at the level of the kyphosis. The bands are gradually and sequentially tightened, bringing the spine into a corrected sagittal position. Patients who underwent this procedure and had at least 1 year of follow-up were identified. Demographic and clinical data, as well as plain radiographic and CT sagittal spine parameters, were analyzed before the surgery and at the most recent follow-up.Results: Eight children, average age 14 years, 10 months, were included in the study with an average follow-up time of 31 months. Revision surgery occurred approximately 3 years following the initial surgery. There was 20 degrees (ranging from an increase of 18 degrees to a decrease of 46 degrees) mean kyphotic angle correction at the site of the failure and 16 degrees (ranging from an increase of 24 degrees to a decrease of 78 degrees) mean cervical lordosis correction, using an average of six sublaminar bands. Before revision, all patients reported neck/upper back pain, with upper rod prominence. At the most recent post-revision visit, pain was markedly reduced, and rod prominence had resolved. One patient reported increased satisfaction with appearance, and another noted that maintaining horizontal gaze was easier.Conclusion: Children who received this surgical technique for PJF experienced resolution of pain and upper rod prominence and improved cervical spine sagittal radiographic parameters that were maintained at least 1 year after revision surgery.Levels of Evidence: IV Key Concepts•PJF is a known complication following posterior spine instrumentation surgery.•PJF is associated with numerous comorbidities.•Scarce literature currently exists on how to revise PJF once it occurs.•Proximal extension of spine instrumentation using paired sublaminar bands was an effective and safe surgical technique to revise PJF for eight children in this study.