Proximal junctional acute collapse cranial to multi-level lumbar fusion: a cost analysis of prophylactic vertebral augmentation

Hart, Robert A.; Prendergast, Michael; Roberts, Warren G.; Nesbit, Gary M.; Barnwell, Stanley L.

doi:10.1016/j.spinee.2008.01.015

Cited by 149 publications

(109 citation statements)

References 33 publications

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“…22,24 However, a subset of PJK, known as "proximal junctional failure" (PJF), has recently been identified as a more severe form of PJK that is associated with an increased need for revision surgery. 4,15,16,18,35,47,48,51 PJF is defined as a > 10° change of kyphosis between the UIV and the vertebra 2 levels above the UIV (UIV+2), along with a fracture in the vertebral body of UIV or UIV+1 and/or a disruption of the posterior osseoligamentous complex and/or pullout of instrumentation at the UIV. 4,15,16,18,35,47,48,51 Even though both PJK and PJF are defined, at least partly, by an increased proximal kyphosis, PJF is thought to represent an entity distinct from PJK with differing pathology and risk factors.…”

Section: Discussionmentioning

confidence: 99%

“…4,15,16,18,35,47,48,51 PJF is defined as a > 10° change of kyphosis between the UIV and the vertebra 2 levels above the UIV (UIV+2), along with a fracture in the vertebral body of UIV or UIV+1 and/or a disruption of the posterior osseoligamentous complex and/or pullout of instrumentation at the UIV. 4,15,16,18,35,47,48,51 Even though both PJK and PJF are defined, at least partly, by an increased proximal kyphosis, PJF is thought to represent an entity distinct from PJK with differing pathology and risk factors. Specifically, PJF appears to result from an acute event rather than from a recurrent deformity 15,48 and has been shown to have a strong association with preoperative spinopelvic mismatch, increased SVA, and increased thoracic kyphosis.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Maggio

Ailon

Smith

et al. 2015

SPI

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OBJECT The associations among global spinal alignment, patient-reported disability, and surgical outcomes have increasingly gained attention. The assessment of global spinal alignment requires standing long-cassette anteroposterior and lateral radiographs; however, spine surgeons routinely rely only on short-segment imaging when evaluating seemingly isolated lumbar pathology. This may prohibit adequate surgical planning and may predispose surgeons to not recognize associated pathology in the thoracic spine and sagittal spinopelvic malalignment. The authors used a case-based survey questionnaire to evaluate if including long-cassette radiographs led to changes to respondents' operative plans as compared with their chosen plan when cases contained standard imaging of the involved lumbar spine only. METHODS A case-based survey was distributed to AOSpine International members that consisted of 15 cases of lumbar spine pathology and lumbar imaging only. The same 15 cases were then shuffled and presented a second time with additional long-cassette radiographs. Each case required participants to select a single operative plan with 5 choices ranging from least to most extensive. The cases included 5 “control” cases with normal global spinal alignment and 10 “test” cases with significant sagittal and/or coronal malalignment. Mean scores were determined for each question with higher scores representing more invasive and/or extensive operative plans. RESULTS Of 712 spine surgeons who started the survey, 316 (44%) completed the entire series, including 68% of surgeons with spine fellowship training and representation from more than 40 countries. For test cases, but not for control cases, there were significantly higher average surgical invasiveness scores for cases presented with long-cassette radiographs (4.2) as compared with those cases with lumbar imaging only (3.4; p = 0.002). The addition of long-cassette radiographs resulted in 82.1% of respondents recommending instrumentation up to the thoracic spine, a 23.2% increase as compared with the same cases presented with lumbar imaging only (p = 0.008). CONCLUSIONS This study demonstrates the importance of maintaining a low threshold for performing standing long-cassette imaging when assessing seemingly isolated lumbar pathology. Such imaging is necessary for the assessment of spinopelvic and global spinal alignment, which can be important in operative planning. Deformity, particularly positive sagittal malalignment, may go undetected unless one maintains a high index of suspicion and obtains long-cassette radiographs. It is recommended that spine surgeons recognize the prevalence and importance of such deformity when contemplating operative intervention.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Maggio

Ailon

Smith

et al. 2015

SPI

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“…Many authors have reported patients who developed spinal stenosis, HNP, instability or PJF at a segment adjacent to a previously fixed segment [1][2][3]. The reported incidence of subsequent PJF after long instrumented fusion is 4-15 % [6][7][8][9].…”

Section: Discussionmentioning

confidence: 99%

Progressive thoracic myelopathy caused by spinal calcium pyrophosphate crystal deposition because of proximal junctional vertebral compression fracture after lumbopelvic fusion

Odate¹,

Shikata²,

Fujibayashi

et al. 2012

Eur Spine J

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Purpose We describe cases presenting with progressive thoracic myelopathy after lumbopelvic fusion attributed to proximal junctional vertebral compression fracture (PJF) followed by spinal calcium pyrophosphate dehydrate (CPPD) crystal deposition. Methods The study included six patients, ranging from 62 to 75 years. All patients had been treated previously with lumbopelvic fusion. The mean period from the detection of PJF to the onset of myelopathy was 4.8 months. Notably, five patients demonstrated upper-instrumented vertebra (UIV) collapse. Results After revision surgery involving decompressive laminectomy and extension of the spinal fusion, all patients experienced significant improvement. Photomicrographs of the resected ligamentum flavum showed CPPD crystals and multinucleated giant cells. Conclusions The combination of mechanical stress plus PJF and CPPD crystal deposition followed by a foreign body reaction to the deposited crystals caused myelopathy. Patients with radiographic evidence of PJF, especially UIV collapse, after lumbopelvic fusion should be followed carefully for the emergence of myelopathy.

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“…Other terms used to describe this phenomenon have included Btopping off syndrome,B proximal junctional fracture,^and Bproximal junctional acute collapse.^These terms highlight the associated structural failure and mechanical instability that distinguish this more severe form of proximal junctional pathology from its more common and more benign PJK counterpart. The estimated cost of revision surgery after PJF is $77,432, indicating a greater clinical and economic burden of this condition [18].…”

Section: Proximal Junctional Failurementioning

confidence: 99%

“…The authors specifically noted that augmentation of only the UIV level provided no statistically significant benefit in preventing proximal junctional fractures. In a clinical study, Hart et al [18] reported that prophylactic vertebroplasty of the UIV and UIV+1 levels not only reduced the risk of PJF but was also cost effective when compared to the cost of a revision procedure. Currently, there is little guidance for surgeons in determining how many levels on which to perform prophylactic cement augmentation.…”

Section: Vertebral Cement Augmentationmentioning

confidence: 99%

Proximal junctional kyphosis and failure—diagnosis, prevention, and treatment

Nguyễn

Kong

Hart

2016

Curr Rev Musculoskelet Med

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Technical advancements have enabled the spinal deformity surgeon to correct severe spinal mal-alignment. However, proximal adjacent segment pathology (ASP) remains a significant issue. Examples include proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). Agreement on the definition, classification, and pathophysiology of PJK and PJF remains incomplete, and an understanding of the risk factors, means of prevention, and treatment of this problem remains to be elucidated. In general, PJK is a relatively asymptomatic radiographic diagnosis managed with patient reassurance and monitoring. On the other hand, PJF is characterized by mechanical instability, pain, and more severe kyphosis, with potential for neurologic compromise. Patients who develop PJF more often require revision surgery than those with PJK. This chapter will review the current understanding of PJK and PJF.

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Proximal junctional acute collapse cranial to multi-level lumbar fusion: a cost analysis of prophylactic vertebral augmentation

Cited by 149 publications

References 33 publications

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons

Progressive thoracic myelopathy caused by spinal calcium pyrophosphate crystal deposition because of proximal junctional vertebral compression fracture after lumbopelvic fusion

Proximal junctional kyphosis and failure—diagnosis, prevention, and treatment

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