Acute Proximal Junctional Failure Research Articles

P96. The lordosis distribution index does not impact failure rates after surgical treatment of adult spinal deformity

BACKGROUND CONTEXT The risk factors for developing proximal junctional failure (PJF) after surgery for adult spinal deformity (ASD) continue to evolve. The lordosis distribution index (LDI) describes the amount of lower arc lordosis (L4-S1) as a fraction of total lumbar lordosis (L1-S1) and has been postulated to influence the outcomes of ASD. PURPOSE The purpose of this study is to determine if the LDI is a risk factor for mechanical failure after ASD. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE Adult patients with ASD treated with thoracolumbar fusion (>4 levels, caudal to T9). METHODS Demographic variables and surgical data were recorded and radiographic data including proximal junctional angle (PJA), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), pelvic incidence (PI), T1 and T9 spinopelvic inclination (T1-SPI and T9-SPI), and LDI were calculated preoperatively, immediately postoperatively and at 6 months, 1 year and 2 years. Patients were categorized by LDI (severe hypolordosis, moderate hypolordosis, aligned and hyperlordosis) pre- and post-operatively along with the change in LDI between the two time points. Acute PJF ( RESULTS There were 187 patients that met the inclusion criteria. Acute PJF occurred in 48 (25.6%) patients. At final follow up, 58 (31.0%) patients underwent surgery for acute PJF or late failure. There was no difference in the prevalence of acute PJF or late failure for patients that were severely hypolordotic (LDI 0.8) at the preoperative and immediate postoperative time points. Similarly, there was no difference in acute PJF or late failure when the amount of change in LDI was considered. Univariate cox proportional hazard models demonstrated the number of levels fused, exclusion of the sacrum and/or pelvis during instrumentation, postoperative change in PI-LL and T9-SPI were predictors of early or late failure. CONCLUSIONS The lordosis distribution index is increasingly recognized as a relevant surgical variable in ASD treatment. This study sought to ascertain the association of LDI with mechanical failure. In this cohort of patients, the LDI did not impact the failure rate. However, this study corroborates previously known risk factors for failure including the number of levels fused, excluding the sacrum/pelvis, and amount of PI-LL mismatch correction. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Prevalence and Indications for Unplanned Reoperations Following Index Surgery in the Adult Symptomatic Lumbar Scoliosis NIH-Sponsored Clinical Trial

Study DesignLongitudinal cohort. ObjectiveTo report on the prevalence and indications for unplanned reoperations following index surgery in the Adult Symptomatic Lumbar Scoliosis NIH-sponsored Clinical Trial. Summary of Background DataReoperation following adult spinal deformity surgery exposes the patient to additional surgical risk, increases the cost of care, and decreases the potential cost-effectiveness of the intervention. Accurate data regarding the prevalence and indication for reoperation will facilitate future efforts to minimize risk. MethodsA total of 153 patients underwent adult spinal deformity surgery as part of the observational, randomized, or crossover groups and were eligible for two-year follow-up. Reoperations were meticulously tracked as part of the National Institutes of Health (NIH)–mandated serious adverse event (SAE) reporting. The primary indication for reoperation was obtained from the treating surgeon’s operative report. ResultsThirty-two patients had one reoperation, two patients underwent two reoperations, and three patients underwent three reoperations. A total of 45 reoperations were performed in 37 patients. Eleven patients (7%) underwent reoperation within 90 days of the index surgery: two for superficial wound dehiscence, three for radiculopathy with screw removal, and six for acute proximal junctional failure (PJF). Four patients underwent reoperation for PJF more than 90 days from index surgery. Twenty-six patients underwent 28 reoperations for rod fracture/pseudoarthrosis. ConclusionIn a consecutive series of adult spinal deformity surgery patients with meticulous follow-up, 24% of patients required an unplanned reoperation. The most common indication for reoperation was rod fracture/pseudoarthrosis, which occurred from 9 months to 3.7 years following the index surgery and accounted for 62% (28/45) of the reoperations. The second most common indication for reoperation was PJF, which occurred from 1 month to 1.6 years following index surgery and accounted for 22% (10/45) of the reoperations. As these complications will likely increase with longer follow-up, efforts to lower the rates of these complications are warranted. Level of EvidenceLevel II.

The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study

Background ContextThe incidence of proximal junctional kyphosis (PJK) ranges from 5% to 46% following adult spinal deformity surgery. Approximately 66% to 76% of PJK occurs within 3 months of surgery. A subset of these patients, reportedly 26% to 47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK and PJF incidence at long-term follow-up. PurposeThe purpose of this study is to evaluate the long-term radiographic and clinical outcomes, and incidence of PJK and PJF, after prophylactic vertebroplasty for long-segment thoracolumbar posterior spinal fusion (PSF). Study DesignThis is a prospective cohort study. Patient SampleThirty-nine patients, of whom 87% were female, who underwent two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF were included in this study. Outcome MeasuresClinical outcomes were assessed using the Scoliosis Research Society-22 (SRS-22), and Short-Form (SF) 36 questionnaires, and the Oswestry Disability Index (ODI). Radiographic parameters including PJK angle, and coronal and sagittal alignment, were calculated, along with relevant perioperative complications and revision rates. MethodsOf the 41 patients who received two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF, and comprised a cohort with previously published 2-year follow-up data, 39 (95%) completed 5-year follow-up (average: 67.6 months). Proximal junctional kyphosis was defined as a change in the PJK angle ≥10° between the immediate postoperative and final follow-up radiograph. Proximal junctional failure was defined as acute proximal junctional fracture, fixation failure, or kyphosis requiring extension of fusion within the first 6 months postoperatively. ResultsThirty-nine patients with a mean age of 65.6 (41–87) years were included in this study. Of the 39 patients, 28.2% developed PJK (11: 7.7% at 2 years, 20.5% between 2 and 5 years), and 5.1% developed acute PJF. Two of the 11 PJK patients required revision for progressive worsening of the PJK. There were no proximal junctional fractures. There was no significant difference in preoperative, immediate postoperative, and final follow-up measurements of thoracic kyphosis, lumbar lordosis, and coronal or sagittal alignment between patients who developed PJK, PJF, or neither (p>.05). There was no significant difference in ODI, SRS-22, or SF-36 scores between those with and without PJK or PJF (p>.05). ConclusionsThis long-term follow-up demonstrates that prophylactic vertebroplasty may minimize the risk for junctional failure in the early postoperative period. However, it does not appear to decrease the incidence of PJK at 5 years.

Predictive factors for acute proximal junctional failure (APJF) after adult deformity surgery: a multivariate analysis

BACKGROUND CONTEXT: Acute proximal junctional failure (APJF), was recently defined as post-operative fracture of the upper instrumented vertebrae (UIV) or UIV+1; UIV implant failure; proximal junctional kyphosis (PJK) increase >15°; or need for proximal extension of the fusion within 6 months of surgery.

Acute Proximal Junctional Failure: A T10 UIV is Not as Safe as Thought

Acute Proximal Junctional Failure: A T10 UIV is Not as Safe as Thought

Acute proximal junctional failure in patients with preoperative sagittal imbalance

Background contextProximal junctional failure (PJF) is a recognized complication of spinal deformity surgery. Acute PJF (APJF) has recently been demonstrated to be 5.6% in the adult spinal deformity (ASD) population. The incidence and rate of return to the operating room for APJF have not been specifically investigated in individuals with sagittal imbalance. PurposeThe purpose of this study was to report the incidence of APJF in patients with preoperative sagittal imbalance and the rate of return to the operating room for APJF. Study design/settingThis study is based on a retrospective review of prospectively collected database of ASD patients. Patient sampleOne hundred seventy-three consecutive patients were included with preoperative sagittal imbalance according to one of the following common parameters: sagittal vertical axis (SVA) greater than 50 mm, global sagittal alignment greater than 45°, or pelvic incidence minus lumbar lordosis greater than 10°. Outcome measuresOutcome measure was presence and/or absence of APJF defined as fracture at the upper instrumented vertebra (UIV) or UIV+1, failure of UIV fixation, 15° or more proximal junctional kyphosis, or need for extension of instrumentation within 6 months of surgery. MethodsWe performed radiographic measurements on X-rays at preoperative, immediate postoperative, and 6-month follow-up visits. The APJF rate was reported for the entire patient population with preoperative sagittal imbalance. Acute PJF incidence was calculated postoperatively for each of the accepted sagittal balance parameters and/or formulas. Patients with persistent postoperative sagittal imbalance were compared with the sagittally balanced group. We also assessed for threshold values. ResultsAcute PJF was observed in 60 of 173 patients (35%) and was least common in fusions with the UIV in the upper thoracic (UT) spine (p=.035). Of those who developed APJF, 21.7% required surgery. Proximal junctional kyphosis 15° or more was the most common form of APJF in fusions to the UT spine but least likely to need revision (p=.014). The most common mode of failure in lower thoracic (LT) or lumbar (L) fusions was UIV fracture. Postoperative SVA less than 50 mm was a significant risk factor for APJF (p=.009). ConclusionsAcute PJF is more common in patients with preoperative sagittal imbalance (35%) than the general adult deformity patient population, and 37% of those with APJF require revision. It is least common when the UIV is in the UT spine, compared with the LT or L spine. Sagittal balance correction to an SVA 50 mm or less was a significant risk factor in patients with preoperative sagittal imbalance.

Predictive Factors for APJF after Adult Deformity Surgery with the UIV in the Thoracolumbar (TL) Spine

Acute Proximal Junctional Failure (APJF), was recently defined by the International Spine Study Group (ISSG) as: postoperative fracture of the upper instrumented vertebrae (UIV) or UIV+1; UIV implant failure; proximal junctional kyphosis (PJK) increase ≥15°; or need for proximal extension of the fusion within 6 months of surgery. The incidence and revision rates of APJF have been reported to be higher when the UIV is located in the lower thoracic or lumbar (TL) spine mostly because of high incidence of UIV or UIV+1 fractures.

Acute Proximal Junctional Failure after Deformity Surgery in Patients Older than 55 Years

Acute Proximal Junctional Failure after Deformity Surgery in Patients Older than 55 Years

Predictive factors for acute proximal junctional failure after adult deformity surgery with upper instrumented vertebrae in the thoracolumbar spine.

Study Type Retrospective cohort study. Introduction Acute proximal junctional failure (APJF) was recently defined by the International Spine Study Group as: postoperative fracture of the upper instrumented vertebrae (UIV) or UIV + 1; UIV implant failure; proximal junctional kyphosis (PJK) increase > 15 degrees; or need for proximal extension of the fusion within 6 months of surgery.1 The incidence and revision rates of APJF have been reported to be higher when the UIV is located in the lower thoracolumbar (TL) spine mostly because of high incidence of UIV or UIV + 1 fractures.2 Sagittal deformity overcorrection has been considered as a potential risk factor.3 4 Objective The purpose of this study is to assess independent predictive factors and timing for revisions of APJF in adult deformity patients with UIV in the TL (T9–L2) spine. Methods Retrospective review of 135 consecutive patients with minimum 2-year follow-up, treated at a single institution for adult spinal deformity, all with UIV in the TL spine (T9–L2). Fusions were divided into three cohorts based on the UIV location (T9–T10 vs. T11–T12 vs. L1–L2). Demographic data were reviewed and radiographic parameters were measured preoperatively, immediately postoperatively, at 6 months and at the final follow-up. Incidence and failure modes of APJF, as well as timing for APJF revision are reported. Risk factors for APJF were assessed with univariate and multivariate regression analysis models. Results A total of 135 consecutive patients were reviewed, with mean follow-up 42 months (24–126). Mean age was 66 years (24–86). There were no differences in the preoperative radiographic parameters between patients in any of the three cohorts with APJF. The incidence of APJF was 38.5%, with a trend toward higher APJF in the T9–T10 group (p = 0.07) (Table 1). When UIV was at T10, the incidence of APJF was 57.1%, significantly higher than the adjacent vertebrae, T9 and T11 (p = 0.03 and p = 0.01, respectively). The overall revision rate for APJF was 17%, most often for UIV fracture, while PJK > 15 degrees alone had the highest 2 and 5 years survival (100%) (Fig. 1). Univariate analysis revealed preoperative sagittal vertical axis > 5 cm, postoperative PJA > 5 degrees and thoracic kyphosis > 30 degrees, and instrumentation to the pelvis as risk factors for APJF (Table 2). Multivariate regression analysis confirmed postoperative PJA > 5 degrees, and greater correction of lumbar lordosis (LL) as independent risk factors for APJF (Table 3). Conclusion The incidence of APJF in adult deformity patients is high if the UIV is in the lower thoracic or lumbar spine, with a trend toward higher rates when the UIV is at T10. Fracture at the UIV lead to the highest revision rate, while PJK > 15 degrees without fracture or hardware failure had the longest revision-free survival. Postoperative PJA > 5 degrees and greater correction of LL are independent risk factors for APJF.

Incidence, Mode, and Location of Acute Proximal Junctional Failures After Surgical Treatment of Adult Spinal Deformity

Multicenter, retrospective series. To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

Identification of Decision Criteria for Revision Surgery Among Patients with Acute Proximal Junctional Failure Following Surgical Treatment for Spinal Deformity

Revision rates for patients with Acute Proximal Junctional Failure (APJF) remain relatively high, yet the decision criteria for performing revision surgeries is not uniform and is often patient-specific. A better understanding of the factors that impact the decision to perform revision surgery is important in order to assess current practices and ultimately improve efficiency of surgical treatment for spinal deformity.

Acute Proximal Junctional Failure Following Long Posterior Fusion for Spinal Deformity: Risk Factors and Radiographic Analysis Comparing Upper Thoracic vs. Thoracolumbar Failures

Acute proximal junctional failure (APJF) is a challenging complication following spinal deformity surgery. The majority of previous reports on APJF are limited to single institution and have not been sufficiently powered to evaluate features associated with APJF. Additionally, few studies compare the morphology of failure and do not separately evaluate upper thoracic and thoracolumbar failures.

Treatment Parameters and Injury Mechanism Associated with Acute Proximal Junctional Failure Following Posterior Spinal Fusion for Deformity

Acute Proximal junctional failure (APJF) has gained increased attention as a complication following spinal deformity surgery. Prior reports have examined the development of proximal kyphosis, however there has been limited evaluation of acute failures. Previous studies have also not been sufficiently powered to evaluate the multiple variables associated with APJF.