Progressive Junctional Kyphosis at the Caudal End of Lumbar Instrumented Fusion: Etiology, Predictors, and Treatment

Kwon, Brian K.; Elgafy, Hossein; Keynan, Ory; Fisher, Charles G.; Boyd, Michael; Paquette, Scott; Dvorak, Marcel F.

doi:10.1097/01.brs.0000229258.83071.db

Cited by 57 publications

(39 citation statements)

References 17 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Long fusion constructs are often associated with instrumentation failure [6,10]. Instrumentation failures result from inadequate fixation, poor bone quality, and multiple levels requiring arthrodesis.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis

et al. 2009

View full text Add to dashboard Cite

There is a debate regarding the distal fusion level for degenerative lumbar scoliosis. Whether a healthy L5-S1 motion segment should be included or not in the fusion remains controversial. The purpose of this study was to determine the optimal indication for the fusion to the sacrum, and to compare the results of distal fusion to L5 versus the sacrum in the long instrumented fusion for degenerative lumbar scoliosis. A total of 45 patients who had undergone long instrumentation and fusion for degenerative lumbar scoliosis were evaluated with a minimum 2 year follow-up. Twenty-four patients (mean age 63.6) underwent fusion to L5 and 21 patients (mean age 65.6) underwent fusion to the sacrum. Supplemental interbody fusion was performed in 12 patients in the L5 group and eleven patients in the sacrum group. The number of levels fused was 6.08 segments (range 4-8) in the L5 group and 6.09 (range 4-9) in the sacrum group. Intraoperative blood loss (2,754 ml versus 2,938 ml) and operative time (220 min versus 229 min) were similar in both groups. The Cobb angle changed from 24.7°before surgery to 6.8°after surgery in the L5 group, and from 22.8°to 7.7°in the sacrum group without statistical difference. Correction of lumbar lordosis was statistically better in the sacrum group (P = 0.03). Less correction of lumbar lordosis in the L5 group seemed to be associated with subsequent advanced L5-S1 disc degeneration. The change of coronal and sagittal imbalance was not different in both groups. Subsequent advanced L5-S1 disc degeneration occurred in 58% of the patients in the L5 group. Symptomatic adjacent segment disease at L5-S1 developed in five patients. Interestingly, the development of adjacent segment disease was not related to the preoperative grade of disc degeneration, which proved minimal degeneration in the five patients. In the L5 group, there were nine patients of complications at L5-S1 segment, including adjacent segment disease at L5-S1 and loosening of L5 screws. Seven of the nine patients showed preoperative sagittal imbalance and/or lumbar hypolordosis, which might be risk factors of complications at L5-S1. For the patients with sagittal imbalance and lumbar hypolordosis, L5-S1 should be included in the fusion even if L5-S1 disc was minimal degeneration.

show abstract

Section: Discussionmentioning

confidence: 99%

“…The L5 pedicles are shorter and more cancellous than those used in the upper lumbar spine. The fixation with two pedicle screws for short and cancellous L5 pedicles may be inadequate for long fusion [2,10].…”

Section: Discussionmentioning

confidence: 99%

Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis

et al. 2009

View full text Add to dashboard Cite

show abstract

“…Adult severe rigid congenital kyphoscoliosis has been a persistent and perplexing problem [19,20,27,37]. The operative or nonoperative treatments often fail, resulting in a three-dimensional deformity at coronal, sagittal, and frontal planes [2,16,29,30].…”

Section: Discussionmentioning

confidence: 99%

A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases

Wang

Zhang

et al. 2008

Eur Spine J

View full text Add to dashboard Cite

We report a multilevel modified vertebral column resection (MVCR) through a single posterior approach and clinical outcomes for treatment of severe congenital rigid kyphoscoliosis in adults. Transpedicular eggshell osteotomies and vertebral column resection are two techniques for the surgical treatment of rigid severe spine deformities. The authors developed a new technique combining the two surgical methods as a MVCR, through a single posterior approach, for surgical treatment of severe congenital rigid kyphoscoliosis in adults. Thirteen adult patients with severe rigid congenital kyphoscoliosis deformity were treated by a single posterior approach using a MVCR technique. The surgery processes included a onestage posterior transpedicular eggshell technique first, and then expanded the eggshell technique to adjacent intervertebra space through abrasive reduction of the vertebral cortices from inside out. All posterior vertebral elements were removed including the cortical vertebral bone around the neural canal. Range of resection of the vertebral column at the apex of the deformity included apical vertebra and both cephalic and/or caudal adjacent wedged vertebrae. Totally, 32 vertebrae had been removed in 13 patients, with 2.42 vertebrae being removed on average in each case. The average fusion extent was 7.69 vertebrae. Mean operation time was 266 min with average blood loss of 2,411.54 ml during operation. Patients were followed up for an average duration of 2.54 years. Deformity correction was 59% in the coronal plane (from 79.7°to 32.4°) postoperatively and 33.7°(57% correction) at 2 years followup. In the sagittal plane, correction was from preoperative 85.9°to 27.5°immediately after operation, and 32.0°at 2 years follow-up. Postoperative pain was reduced from preoperative 1.77 to 0.54 at 2 years follow-up in visual analog scale. SRS-24 scale was from 38.2 preoperatively to 76.9 at 2 years follow-up postoperative. Complications were encountered in four patients (30.7%) with transient neurology that spontaneously improved without further treatment within 3 months. MVCR technique through a single posterior approach is an effective procedure for the surgical treatment of severe congenital rigid kyphoscoliosis in adults.

show abstract

“…ASD at the lower adjacent segment may also occur due to failure of the most distal fixation, positive sagittal balance, younger age, or preoperative radiographic degeneration [8,9].…”

Section: Introductionmentioning

confidence: 99%

Effects of rod stiffness and fusion mass on the adjacent segments after floating mono-segmental fusion: a study using finite element analysis

Jin

Kim²,

Seo³

et al. 2012

Eur Spine J

View full text Add to dashboard Cite

Purpose The aims of the present study were to compare the biomechanical effects on the adjacent segments after mono-segmental floating fusion with posterior semi-rigid or rigid stabilization, and to evaluate the effect of the amount of fusion mass on the biomechanical differences. Methods A detailed, nonlinear L1-S1 finite element model had been developed and validated. Then five models were reconstructed by different fixation techniques on the L3-L4 level: rigid fixation with an interbody spacer (Ti ? IS), rigid fixation with a large interbody spacer (Ti ? IS_all), semi-rigid fixation with an interbody spacer (PEEK ? IS), semi-rigid fixation with a large interbody spacer (PEEK ? IS_all), and semi-rigid fixation only (PEEK). Analyses were conducted for the case of erect standing position, flexion, and extension motion. Results At L1-L2 and L2-L3, PEEK ? IS demonstrated less inter-segmental rotation and nucleus pressure increments from the intact model compared with Ti ? IS. The L4-L5 and L5-S1 levels showed slightly higher values with PEEK ? IS, but these differences among the instrumented models were not significant. The motion difference based on the fusion mass at the adjacent levels was at most 3 %. All instrumentation cases generated a 55 % higher facet contact force at the lower adjacent level (L4-L5) compared to that of the intact model during 26°e xtension and the largest increment was detected at the upper adjacent level (L2-L3) in the Ti ? IS. Instrumentation with Ti ? IS markedly increased the stress in the intervertebral disk at the upper adjacent level, while the stress with PEE-K ? IS appeared largest at the lower adjacent level. Conclusions Posterior instrumentation with semi-rigid rods may lower the incidence of disk and facet degeneration in the upper adjacent segment compared to rigid rods. On the other hand, the possibility of facet degeneration will be similar for all instrumentation devices in the lower adjacent segment in the long-term. The stiffness difference between rigid and semi-rigid rods on the changes in the adjacent motion segments was more crucial than amount of fusion mass.

show abstract

Progressive Junctional Kyphosis at the Caudal End of Lumbar Instrumented Fusion: Etiology, Predictors, and Treatment

Cited by 57 publications

References 17 publications

Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis

Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis

A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases

Effects of rod stiffness and fusion mass on the adjacent segments after floating mono-segmental fusion: a study using finite element analysis

Contact Info

Product

Resources

About