Introduction
Proximal junctional kyphosis (PJK) is a relatively common complication following spinal deformity surgery that may require reoperation. Although isolating the incidence is highly ...variable, in part due to the inconsistency in how PJK is defined, previous studies have reported the incidence to be as high as 39% with revision surgery performed in up to 47% of those with PJK. Despite the discordance in reported incidence, PJK remains a constant challenge that can result in undesirable outcomes following adult spine deformity surgery.
Methods
A comprehensive literature review using Medline and PubMed was performed. Keywords included “proximal junctional kyphosis,” “postoperative complications,” “spine deformity surgery,” “instrumentation failure,” and “proximal junctional failure” used separately or in conjunction.
Results
While the characterization of PJK is variable, a postoperative proximal junction sagittal Cobb angle at least 10°, 15°, or 20° greater than the measurement preoperatively, it is a consistent radiographic phenomenon that is well defined in the literature. While particular studies in the current literature may ascertain certain variables as significantly associated with the development of proximal junctional kyphosis where other studies do not, it is imperative to note that they are not all one in the same. Different patient populations, outcome variables assessed, statistical methodology, surgeon/surgical characteristics, etc. often make these analyses not completely comparable nor generalizable.
Conclusions
The goal of adult spine deformity surgery is to optimize patient outcomes and mitigate postoperative complications whenever possible. Due to the multifactorial nature of this complication, further research is required to enhance our understanding and eradicate the pathology. Patient optimization is the principal guideline in not only PJK prevention, but overall postoperative complication prevention.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
Purpose
Pelvic incidence (PI) is assumed to be fixed, yet studies have reported PI changes after long fusions to the pelvis. In a cohort of ASD patients undergoing surgery with S2-alar-iliac (S2AI) ...screws, we sought to: (1) report the magnitude of PI changes, and (2) evaluate subsequent pelvic parameter changes.
Methods
A retrospective case series of ASD patients undergoing surgical correction with S2AI screw placement and sagittal cantilever correction maneuvers was conducted. Patients were categorized based on preoperative PI: High-PI (H-PI) (PI ≥ 60°); Normal-PI (N-PI) (60° > PI > 40°); Low-PI (L-PI) (PI ≤ 40°). PI was measured preoperatively and immediately postoperatively. A significant PI change was established a priori at ≥ 6.0. PI, pelvic tilt (PT), lumbar lordosis (LL), and PI-LL mismatch were analyzed.
Results
In 68 patients (82.3% female, ages 22–75 years), the average change in PI was 4.6° ± 3.1, and 25 (36.8%) had a PI change ≥ 6.0° with breakdown as follows: H-PI 12 (66.7%) patients, 9 (25.87%) patients, and 4 (33.3%) patients. Of 25 patients with PI changes, 10 (14.7%) had a PI increase and 15 (22.1%) had a PI decrease. Significant improvements were seen in PT, LL, PI-LL mismatch in all patients with a PI change ≥ 6.0°, in addition to both subgroups with an increase or decrease in PI.
Conclusions
PI changes of ≥ 6.0° occurred in 36.8% of patients, and H-PI patients most commonly experienced PI changes. Despite PI alterations, pelvic parameters significantly improved postoperatively. These results may be explained by sacroiliac joint laxity, S2AI screw placement, or aggressive sagittal cantilever techniques.
STUDY DESIGN.Retrospective review of a prospectively collected multicenter database.
OBJECTIVE.To assess how “overcorrection” of the main thoracic curve without control of the proximal curve ...increases the risk for shoulder imbalance in Lenke type 1 Adolescent Idiopathic Scoliosis (AIS).
SUMMARY OF BACKGROUND DATA.Postop shoulder imbalance is a common complication following AIS surgery. It is thought that a more cephalad upper-instrumented vertebra (UIV) decreases the risk of shoulder imbalance in Lenke type 1 and 2 curves; however, this has not been proven.
METHODS.Thirteen surgeons reviewed preop and 5-year postop clinical photos and PA radiographs of patients from a large multicenter database with Lenke type 1 and 2 AIS curves who were corrected with pedicle screw/rod constructs. Predictors of postop shoulder imbalance were identified by univariate analysis; multivariate analysis was done using the classification and regression tree method to identify independent drivers of shoulder imbalance.
RESULTS.One hundred forty-five patients were reviewed. The UIV was T3-T5 in 87% of patients, with 8.9% instrumented up to T1 or T2. Fifty-two (36%) had shoulder imbalance at 5 years. On classification and regression tree analysis when the proximal thoracic (PT) Cobb angle was corrected more than 52%, 80% of the patients had balanced shoulders. Similarly, when the PT curve was corrected less than 52% and the main thoracic (MT) curve was corrected less than 54%, 87% were balanced. However, when the PT curve was corrected less than 52%, and the MT curve was corrected more than 54%, only 41% of patients had balanced shoulders (P = 0.05). This relationship was maintained regardless of the UIV level.
CONCLUSION.In Lenke type 1 and 2 AIS curves, significant correction of the main thoracic curve (>54%) with simultaneous “under-correction” (<52%) of the upper thoracic curve resulted in shoulder height imbalance in 59% of patients, regardless of the UIV. This suggests the PT curve must be carefully scrutinized in order to optimize shoulder balance, especially when larger correction of the MT curve is performed.Level of Evidence2
Background. Spinal alignment can have a significant impact on a patient’s overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. ...The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex. Materials and Methods. Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. Results. MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was −0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1–S1 lumbar lordosis (LL) was −57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was −5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤−10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)−0.2 (age) ( r =0.75). Conclusions. LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL. Level of Evidence. Level II—prospective cohort study.
STUDY DESIGN.Retrospective cohort study
OBJECTIVE.This study seeks to identify recent trends in utilization and reimbursements of these procedures between 2012and 2017, a period which experienced a ...change in national guideline recommendations for these procedures.
SUMMARY OF BACKGROUND DATA.Minimally invasive vertebral augmentation procedures, including vertebroplasty and kyphoplasty, have been typically reserved for fractures associated with refractory pain, deformity, or progressive neurological symptoms. However, controversy exists regarding the safety and effectiveness of these procedures, in particular vertebroplasty.
METHODS.Annual Medicare claims and payments to surgeons were aggregated at the county level to assess regional trends. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to examine associations between county-specific variables and outcome variables.
RESULTS.A total of 24,316 vertebroplasties and 138,778 kyphoplasties were performed in the Medicare population between 2012 and 2017. Annual vertebroplasty volume fell by 48.0% from 5744 procedures in 2012 to 2987 in 2017, with a compound annual growth rate (CAGR) of −12.3%. Annual kyphoplasty volume also declined by 12.7% (CAGR −2.7%), from 24,986 in 2012 to 21,681 in 2017. Surgeon reimbursements for vertebral augmentation procedures increased by a weighted average of 93.7% (inflation-adjusted increase of 78.2%) between 2012 and 2017, which was primarily driven by a dramatic 113.3% (inflation-adjusted increase of 96.2%) increase in mean reimbursements for kyphoplasty procedures from an average of $895 to $1764, between 2012 and 2017, respectively.
CONCLUSION.This large national Medicare database study found that vertebroplasty and kyphoplasty procedure volume and utilization of both procedures have declined significantly. Although average reimbursements to surgeons for vertebroplasties have significantly declined, payments for kyphoplasty procedures have risen significantly. Although vertebroplasty volume has significantly decreased, it is still being performed and being reimbursed for, in spite of its controversial role in its treatment of vertebral fractures.Level of Evidence3
Study design
Retrospective National Database Study.
Objective
Surgical intervention with spinal fusion is often indicated in cerebral palsy (CP) patients with progressive scoliosis. The purpose of ...this study was to utilize the National Readmission Database to determine the national estimates of complication rates, 90-day readmission rates, and costs associated with spinal fusion in adult patients with CP.
Methods
The 2012–2015 NRD databases were queried for all adult (age ≥ 19 years) patients diagnosed with CP (ICD-9: 333.71, 343.0-4, and 343.8-9) undergoing spinal fusion (ICD-9: 81.00-08).
Results
1166 adult patients with CP (42.7% female) underwent spinal fusion surgery between 2012 and 2015. 153 (13.1%) were readmitted within 90 days following the primary surgery, with a mean 33.8 ± 26.5 days. Mean hospital charge of the primary admission was $141,416 ± $157,359 and $167,081 ± $145,416 for the non-readmitted and readmitted patients, respectively (
p
= 0.06). The mean 90-day readmission charge was $72,479 ± $104,100. Most common complications with the primary admission included UTIs (no readmission vs. readmission: 7.6% vs. 4.8%;
p
= 0.18), respiratory (6.9% vs. 5.6%;
p
= 0.62), implant (3.8% vs. 6.0%;
p
= 0.21), and paralytic ileus (3.6% vs. 3.2%;
p
= 0.858). Multivariate analyses demonstrated the following as independent predictors for 90-day readmission: comorbid anemia (OR: 2.8; 95% CI: 1.6–4.9;
p
< 0.001), coagulopathy (2.9, 1.1–8.0, 0.037), perioperative blood transfusion (2.0, 1.1–3.8, 0.026), wound complication (6.4, 1.3–31.6, 0.023), and transfer to short-term hospital versus routine disposition (4.9, 1.0–23.3, 0.045).
Conclusion
Quality improvement efforts should be aimed at reducing rates of infection related complications as this was the most common reason for short-term complications and unplanned readmission following surgery.
•Rigid thorcolumbar hyperlordosis is a rare spine pathology that is seldom described in literature.•The reverse posterior column osteotomy technique can reliably correct fixed thorcolumbar ...hyperlordosis deformity.•This care report will further elucidate surgical techniques involving the reverse posterior column osteotomy.
Case report.
There is limited literature describing rigid thoracolumbar hyperlordosis correction. This case will highlight the reverse posterior column osteotomy (rPCO) technique to correct rigid thorcolumbar hyperlordosis, which is rarely described in literature.
Rigid thorcolumbar hyperlordosis is an infrequently encountered pathology. There is a paucity of surgical approach described in literature to correct this deformity.
A 21-year-old female patient with a history of adolescent idiopathic scoliosis presented with cervicothoracic proximal junctional kyphosis and a fixed thorcolumbar hyperlordosis after two previous spine surgeries with the final construct fusing from T3-L4.
Patient underwent deformity correction involving T3 vertebral column resection and rPCO’s at T12-L3 to correction regional and global sagittal malalignment.
The rPCO technique can reliably correct fixed thorcolumbar hyperlordosis.
Deviations from a conventional physiologic posture are often a cause of complaint. According to current literature, the upright physiological spine posture exhibits inclinations in the sagittal plane ...but not in the coronal and transverse planes, but individual vertebral body positions of asymptomatic adults have rarely been described using surface topography. Therefore, this work aims to form a normative reference dataset for the thoracic and lumbar vertebral bodies and for the pelvis in all three planes in asymptomatic women.
In a prospective, cross-sectional, monocentric study, 100 pain-free asymptomatic women, aged 20-64 years were enrolled. Habitual standing positions of the trunk were measured using surface topography. Data were analyzed in all three planes. Age sub-analysis was: 1) ages ≤ 40 years and 2) ages ≥ 41 years. Two-sample t-tests were used for age comparisons of the vertebral bodies, vertebra prominence (VP)-L4, and global parameters. One-sample t-tests were used to test deviations from symmetrical zero positions of VP-L4.
Coronal plane: on average, the vertebral bodies were tilted to the right between the VP and T4 (maximum: T2 - 1.8° ± 3.2), while between T6 and T11 they were tilted to the left (maximum: T7 1.1° ± 1.9). T5 and L2 were in a neutral position, overall depicting a mean right-sided lateral flexion from T2 to T7 (apex at T5). Sagittal plane: the kyphotic apex resided at T8 with - 0.5° ± 3.6 and the lumbar lordotic apex at L3 with - 2.1° ± 7.4. Transverse plane: participants had a mean vertebral body rotation to the right ranging from T6 to L4 (maximum: T11 - 2.2° ± 3.5). Age-specific differences were seen in the sagittal plane and had little effect on overall posture.
Asymptomatic female volunteers standing in a habitual posture displayed an average vertebral rotation and lateral flexion to the right in vertebral segments T2-T7. The physiological asymmetrical posture of women could be considered in spinal therapies. With regard to spinal surgery, it should be clarified whether an approximation to an absolutely symmetrical posture is desirable from a biomechanical point of view? This data set can also be used as a reference in clinical practice.
This study was registered with WHO (INT: DRKS00010834) and approved by the responsible ethics committee at the Rhineland-Palatinate Medical Association (837.194.16).
Purpose
Preoperative shoulder balance is an important factor in determining the upper instrumented vertebrae (UIV). In adolescent and adult idiopathic scoliosis (AIS/AdIS) patients, we studied the ...intraobserver and interobserver reliability of spinal surgeons’ assessment of preoperative shoulder balance using X-rays (XR) and anterior/posterior photographs.
Methods
An observational review of a prospective multicenter database (AIS Lenke Type 1/5/6) and prospective single-institution database (AdIS) was conducted. Ten spine surgeons reviewed AIS cases; 12 spine surgeons reviewed AdIS cases. Surgeons rated the higher shoulder:
left/right/same/unsure.
Reliability was calculated using Fleiss’ kappa coefficient.
Results
Among
145 Type 1 AIS cases
, intraobserver reliability was moderate-to-substantial: XR (
κ
= 0.59), anterior photographs (
κ
= 0.68), posterior photographs (
k
= 0.65). Interobserver reliability was fair to moderate for XR (
κ
= 0.31), anterior photographs (
κ
= 0.20), and posterior photographs (
κ
= 0.30). Among
52 Type 5/6 AIS cases
, intraobserver reliability was substantial: XR (κ = 0.70), anterior photographs (κ = 0.76), posterior photographs (
κ
= 0.71). Interobserver reliability was fair to moderate for XR (
κ
= 0.49), anterior photographs (
κ
= 0.47), and posterior photographs (
κ
= 0.36). Among
66 AdIS cases,
intraobserver reliability was substantial: XR (
κ
= 0.68), anterior photographs (
κ
= 0.67), posterior photographs (
κ
= 0.69). Interobserver reliability was moderate for XR (
κ
= 0.45), anterior photographs (
κ
= 0.43), posterior photographs (
κ
= 0.49). Within Type 1 AIS patients, attendings had better intraobserver reliabilities compared to fellows using X-rays (
κ
= 0.61 vs. 0.53), yet no effect of surgeon experience was seen with clinical photographs.
Conclusion
Though surgeons’ ability to agree with themselves was moderate to substantial, surgeons’ ability to agree with each other was fair to moderate. Combined measures to assess preoperative shoulder balance are needed for UIV selection.
Introduction
Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity ...motor function is unknown.
Objective
To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5 years after surgical correction of complex ASD.
Design
Retrospective analysis of a prospective, multicenter, international observational study.
Methods
The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient.
Results
Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6 months, 9.5% at 2 years and 9.3% at 5 years postoperative. During the 2–5 year window, while mean LEMS did not change significantly (−0.5,
p
= 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a
major
surgery-related complication, mean LEMS were significantly lower in patients with
neurologic
surgery-related complications at discharge (
p
= 0.041) and 6 months (
p
= 0.008) between the two groups as well as the change from baseline to 5 years (
p
= 0.041).
Conclusions
In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5 years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5 years postoperative. These results underscore the importance of long-term follow-up to 5 years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up.
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