Surgical Management of Vertebral Body Fractures in Proximal Junctional Kyphosis: A Case Series Utilizing Intravertebral Reduction Devices and Hardware Extension

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Vertebral body fracture is the most common manifestation of proximal junctional failure (PJF), a frequent complication following adult spinal deformity surgery and a leading cause of reoperation(1). In the absence of established consensus regarding optimal revision techniques for PJF, this case report presents two patients with non-traumatic vertebral fractures secondary to PJF, successfully managed with intravertebral reduction device (SpineJack®) and bone cement augmentation, combined with the extension of previous instrumentation. While the etiology of PJF in these two cases remains undetermined, this report aims to contribute to the evolving literature on surgical revision strategies for PJF, particularly in the context of vertebral fractures. The first case involves a 62-year-old female with degenerative scoliosis, flat back deformity, adult idiopathic scoliosis, coronal malalignment, and degenerative disc disease with lateral listhesis underwent lateral lumbar interbody fusion (LLIF) at L2-3, L3-4, and L4-5 with titanium interbody devices and posterior L1 to pelvis instrumentation and fusion. Following L1 compression fracture at the proximal end of the instrumentation, the patient underwent surgical revision at 6 weeks postoperative. The pedicle screws at L1 were explanted, and the pedicle tracks were utilized for open placement of SpineJack® implants under fluoroscopic guidance to reduce and elevate the compressed L1 vertebra, restoring anterior vertebral height. The postoperative course was unremarkable, and the patient exhibited significant clinical improvement. The second case involves a 60-year-old female patient with a history of painful thoracolumbar scoliosis who underwent a T8-Pelvis posterior spinal fusion (PSF) with multiple Smith-Petersen osteotomies (SPOs) and L4-S1 transforaminal lumbar interbody fusion (TLIF) with right-sided instrumentation. Following discovery of a T8 vertebral compression fracture at 8 weeks postoperative, existing hardware at the fracture level was removed, and SpineJack® implants were inserted bilaterally into T8, under fluoroscopic direction. The patient’s postoperative course was unremarkable with significant clinical improvement in pain and neurological function. This report aims to contribute to the literature on surgical strategies for managing vertebral fractures associated with PJF. The use of SpineJack® with cement augmentation appears effective in restoring vertebral body height and spinal alignment while offering a less invasive alternative to more extensive procedures like vertebral column resection (VCR). This technique may offer promising results for spine surgeons addressing vertebral fractures in the context of PJF. While the limitations inherent to case reports preclude establishment of intravertebral reduction devices with cement augmentation as a standard clinical practice guideline for vertebral fractures in the setting of proximal junctional kyphosis and/or failure (PJK/PJF), the successful treatment of two patients with this combined approach aims to contribute to the existing literature by presenting the safety and efficacy of such a technique. It suggests its potential utility for spine surgeons encountering this PJF vertebral fractures moving forward.