A Systematic Review of Risk Factors Associated With Distal Junctional Failure in Adult Spinal Deformity Surgery

Abstract

Background: The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood.Study Design: A systematic review was carried out.Objectives: The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF.Methods: A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and metaanalyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF.Results: Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P = 0.08; relative risk (RR) = 1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P = 0.09; RR = 1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P = 0.06; RR = 1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P = 0.02; RR = 3.28).Conclusions: Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further highquality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.

Patient-specific spinal rods in adult spinal deformity surgery reduce proximal junctional failure: a review of patient outcomes and surgical technique in a prospective observational cohort

“…Late complications experienced were DJF [4/20 (20%)], PJK [8/20 (40%)], PJF [1/20 (5%)]. This is higher than the reported DJF rate of 3.6% but less than the reported PJF rate of up to 35% ( 17 , 19 ). Our cohorts PJK rate was less than findings that over half of ASD surgical patients develop PJK ( 20 ).…”

“…McDonnell et al [2021] stated that anterior-posterior (versus posterior-only) surgery, fusion to the sacrum, and younger age (<60 years) were protective of DJF with conventional rod use. The need for an interbody fusion at L5/S1 is controversial with conflicting reports about the benefit and complication rate ( 17 ). In our series, all patients who suffered DJF reported high decisional regret.…”

“…Proximal junctional failure (PJF) requiring surgery is substantially more common (35%) than distal junctional failure (DJF) (4%) ( 15 - 20 ). However, whilst PJK and PJF have been widely reported, DJF has been less studied ( 17 ).…”

Risk Factors for Distal Junctional Problems Following Long Instrumented Fusion for Degenerative Lumbar Scoliosis: Are they Related to the Paraspinal Muscles

“…This finding indicates that although the incidence of DJPs is lower than that of PJK/PJF, affected patients are more likely to require revision surgery when they occur 8,9 . The pathogenic mechanisms underlying DJPs are multifactorial, and older age, 7 large preoperative sagittal parameters, 10 fusion short of including the first lordotic disc, 11 selection of the incorrect lowest instrumented vertebra (LIV), 12,13 and inability to match the postoperative sagittal plane with the pelvic incidence (PI) 14 have been reported to be involved. Recently, lower muscularity and higher fatty degeneration have been reported as risk factors for PJK 15 .…”

“…The natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) have widely reported, 4–6 but distal junctional problems (DJPs), including distal junction kyphosis/failure (DJK/DJF), have rarely been reported in the literature. A systematic review of 12 studies showed that the incidence of DJF was only 3.6%, but it represented 27.3% of all revision surgeries 7 . This finding indicates that although the incidence of DJPs is lower than that of PJK/PJF, affected patients are more likely to require revision surgery when they occur 8,9 .…”