Age-Adjusted Alignment Goals Have the Potential to Reduce PJK

Lafage, Renaud; Schwab, Frank J.; Glassman, Steve; Bess, Shay; Harris, Bradley; Sheer, Justin K.; Hart, Robert A.; Line, Breton; Henry, Jensen K.; Burton, Doug; Kim, HanJo; Klineberg, Eric O.; Ames, Christopher P.; Lafage, Virginie

doi:10.1097/brs.0000000000002146

Cited by 197 publications

(188 citation statements)

References 33 publications

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“…There is growing consensus that more judicious, ageappropriate sagittal plane deformity correction might help reduce the incidence of PJK. 9 Other strategies to reduce PJK include cement augmentation at or above the upper instrumented vertebrae (UIV) and a "soft landing" at the top of the construct. [10][11][12][13][14][15][16][17] None of these approaches, however, address the posterior ligamentous structures (PLS) at the UIV.…”

Section: Introductionmentioning

confidence: 99%

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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Study Design: Retrospective cohort study.Objectives: Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year. Methods: A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIVÀ1 with a surgical nylon tape while PLSÀ patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts. Results: A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLSÀ (28.6%) were similar (P ¼ .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P ¼ .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK. Conclusion: Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.

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Section: Introductionmentioning

confidence: 99%

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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“…Importantly, age should be considered when planning a deformity correction, as older patients tolerate a higher degree of sagittal imbalance and overcorrection beyond age-adjusted targets contributes to proximal junctional kyphosis. 15 Our results should be considered in the context of many limitations. First, because of the retrospective nature, the patients were not matched or randomized and thus, are subject to selection bias and confounding.…”

Section: Discussionmentioning

confidence: 92%

“…308). 14 In a prospective study, Lafage et al 15 found PT and SVA correlated with HRQOL measures, but found the most significant correlations with T1SPi. 4 Thus, correction of SVA, PT, LL-PI, and T1SPi have become primary objectives of adult spinal deformity surgery.…”

Section: Discussionmentioning

confidence: 97%

Anterior Column Realignment (ACR) With and Without Pre-ACR Posterior Release for Fixed Sagittal Deformity

et al. 2019

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Background: Multiple studies have demonstrated a strong correlation between sagittal malalignment and healthrelated quality of life measures. Thus, correction of sagittal vertical axis (SVA), pelvic tilt (PT), lumbar lordosis-pelvic incidence (LL-PI), and T1 spinopelvic inclination (T1SPi) have become a primary objective of adult spinal deformity surgery. Anterior column realignment (ACR) has emerged as a less invasive technique and while the addition of posterior osteotomies has shown greater correction in ACR, it is unknown if a pre-ACR posterior release is necessary for optimal correction. The purpose of this study was to determine if pre-ACR posterior release allows for greater sagittal deformity correction. Methods: Seventeen patients were identified that underwent minimum 1-level ACR. Ten patients underwent an anterior-posterior surgical sequence without a pre-ACR posterior release, and 7 underwent a posterior-anteriorposterior (PAP) sequence with a pre-ACR posterior release. Radiographic outcomes at final follow-up and complications were compared. Results: Both groups saw significant improvements in LL, LL-PI, PT, SVA, and T1SPi but the correction was not significantly different between cohorts. With the exception of PT in the PAP group, the improvements in LL-PI, PT, and SVA correlated to improvement in Scoliosis Research Society-Schwab classification. The correction achieved at the ACR level, represented by motion segment angle, was greater in the PAP group by a degree that approached statistical significance. Five patients (29%) had 6 complications. Conclusions: Both techniques achieved meaningful improvements in overall sagittal alignment. Our results suggest that a pre-ACR posterior release may allow for greater correction specifically at the ACR level but may not always be necessary to achieve clinically meaningful correction of sagittal plane deformity.

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“…To achieve balance, the demand on the paraspinal muscles to maintain spinal stability naturally increases, and it becomes reasonable to assume that these patients will have greater back pain or fatigue in the sitting position. Proposed age-adjusted and sitting values for sagittal realignment surgeries may further in uence future surgical strategies [18][19][20] .…”

Section: Discussionmentioning

confidence: 99%

Differences in Standing and Sitting Spinopelvic Sagittal Alignment for Patients with Posterior Lumbar Fusion: Important Considerations for the Changes of Unfused Adjacent Segments Lordosis

Sun

Zhou

Wang

et al. 2020

Preprint

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Objective: This study aimed to describe the changes in spinopelvic sagittal alignment in the sitting position after posterior lumbar fusion, and to identify the factors influencing unfused adjacent segment lordosis.Methods: Consecutive patients with lumbar degenerative disease who underwent posterior lumbar interbody fusion between December 2010 and April 2012 were recruited. Lateral full spine radiographs were obtained in the standing, erect sitting, and natural sitting positions. Spinopelvic parameters were measured preoperatively and at the final follow-up. Results: The data of 63 patients were analyzed in this study. The average age was 61.6±11.0 years. When changing from standing to sitting at the final follow-up, all spinopelvic sagittal parameters with the exceptions of pelvic incidence and thoracic kyphosis were significantly altered. The most noticeable changes occurred in the natural sitting position, with the spine slumped toward achieving a C-shaped sagittal profile. Multiple linear regression analysis revealed that when changing to a natural sitting position, age and fusion levels reflected the changes in lumbar lordosis (ΔLL), age and lumbosacral fusion reflected the changes in upper residual lordosis (ΔURL). Conclusion: The most noticeable changes in spinopelvic sagittal alignment occurred in the natural sitting position after lumbar fusion. Age, fusion levels, and lumbosacral fusion significantly influenced the differences in LL and URL between the standing and natural sitting position. These characteristics should be fully considered when planning spinal realignment surgery and investigating the etiological factors of junctional complications.

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Age-Adjusted Alignment Goals Have the Potential to Reduce PJK

Abstract: 3.

Cited by 197 publications

References 33 publications

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Anterior Column Realignment (ACR) With and Without Pre-ACR Posterior Release for Fixed Sagittal Deformity

Differences in Standing and Sitting Spinopelvic Sagittal Alignment for Patients with Posterior Lumbar Fusion: Important Considerations for the Changes of Unfused Adjacent Segments Lordosis

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