Selection of the Optimal Distal Fusion Level in Posterior Instrumentation and Fusion for Thoracic Hyperkyphosis: The Sagittal Stable Vertebra Concept

Cho, Kyu Jung; Lenke, Lawrence G.; Park, Seung Rim; Moon, Kyoung Ho; Kang, Joon Soon; Ban, Jun Ho

doi:10.4184/jkss.2004.11.4.253

Cited by 18 publications

(47 citation statements)

References 17 publications

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“…• For thoracic hyperkyphosis with normal thoracolumbar and lumbar alignment, fusion should be from the upper limit of the thoracic kyphosis (frequently T2) cranially to the sagittally stable vertebra (SSV) caudally [9]. The SSV is the most cranial lumbar vertebra, which is crossed by the vertical line through the posterior corner of the S1 endplate.…”

Section: Surgical Planningmentioning

confidence: 99%

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

et al. 2014

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Section: Surgical Planningmentioning

confidence: 99%

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

et al. 2014

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“…Much of the research effort in this field has focused on calculation of the amount of correction needed in degenerative or postsurgical sagittal imbalance [1,[8][9][10] and identification of ideal fusion levels in thoracic kyphosis (TK) [11]. Some problems remain unsolved, such as the ideal proximal level to fuse in degenerative or postsurgical imbalance, or identification of patients at risk of proximal junctional kyphosis [12].…”

Section: Introductionmentioning

confidence: 99%

Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms

2014

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Introduction Sagittal balance is an independent predictor of clinical outcomes in spinal care. Surgical treatment is challenging and jeopardized by frequent complications. Guidelines for surgical treatment are currently not based on a classification of the disease. A comprehensive classification of sagittal balance based on regional deformities and compensatory mechanisms combined in deformity patterns is proposed. Though the sagittal shape of the spine can change due to degeneration or trauma, correlations between sagittal shape parameters and pelvic incidence (PI) have been described. Pelvic incidence is not changed by degeneration, thus representing a permanent source of information on the original sagittal shape of the spine. Methods One hundred and twenty-eight full-spine lateral standing radiographs of patients with different spinal conditions were evaluated and classified by one rater. One random subseries of 35 patients was evaluated by two raters for calculation of inter-rater agreement. Spinopelvic parameters were measured in all the radiographs. Internal validity of the classification system was evaluated comparing the values of regional sagittal parameters that distinguish one category from the others. Results Eight different patterns were identified regarding the site of the deformity and the presence of compensatory mechanisms: cervical, thoracic, thoracolumbar junction, lumbar, lower lumbar, global and pelvic kyphosis and normal sagittal alignment. Inter-rater agreement was almost perfect (j = 0.963). Statistically significant differences were found comparing the means of selected sagittal spinopelvic parameters that conceptually divide pairs or groups of categories: C2-C7 SVA for cervical kyphosis vs all other patients, TK-PI mismatch for thoracic kyphosis vs all other patients, T11-L2 kyphosis for thoracolumbar kyphosis vs all other patients, global alignment (LL?TK-PI) and SVA for lumbar kyphosis vs global kyphosis and pelvic tilt for pelvic kyphosis vs lumbar, lower lumbar and global kyphosis. Conclusion A comprehensive classification of sagittal imbalance is presented. This classification permits a better interpretation of the deformity and muscle forces acting on the spine, and helps surgical planning. Preliminary validation has been provided.

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“…Indications to extend fixation and fusion to the PT spine include structural scoliosis, thoracic hyperkyphosis, thoracolumbar junctional kyphosis, more severe coronal and sagittal plane decompensation, and osteoporosis. 3,12,18 Proximal thoracic UIV has also been associated with a higher prevalence of pseudarthrosis, a longer operative time, greater blood loss, and a longer hospital stay. 19 However, there is little available information to guide informed decision making in the choice of UIV fusion with respect to PJK, postoperative sagittal plane change, and prevalence of revision surgery after long instrumented fusion to the sacrum in adults.…”

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Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Maruo

Racine

et al. 2013

SPI

140

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Object Proximal junctional kyphosis (PJK) is a common and significant complication after corrective spinal deformity surgery. The object of this study was to compare—based on clinical outcomes, postoperative proximal junctional kyphosis rates, and prevalence of revision surgery—proximal thoracic (PT) and distal thoracic (DT) upper instrumented vertebra (UIV) in adults who underwent spine fusion to the sacrum for the treatment of spinal deformity. Methods In this retrospective study the authors evaluated clinical and radiographic data from consecutive adults (age > 21 years) with a deformity treated using long instrumented posterior spinal fusion to the sacrum in the period from 2007 to 2009. The PT group included patients in whom the UIV was between T-2 and T-5, whereas the DT group included patients in whom the UIV level was between T-9 and L-1. Perioperative surgical data were compared between the PT and DT groups. Additionally, segmental, regional, and global spinal alignments, as well as the sagittal Cobb angle at the proximal junction, were analyzed on preoperative, early postoperative, and final standing 36-in. radiographs. Patient-reported outcome measurements (visual analog scale, Scoliosis Research Society Patient Questionnaire-22, Oswestry Disability Index, and the 36-Item Short-Form Health Survey) were compared. Results Eighty-nine patients, 22 males and 67 females, had a minimum follow-up of 2 years, and thus were eligible for participation in this study. Sixty-seven patients were in the DT group and 22 were in the PT group. Operative time (p = 0.387) and estimated blood loss (p < 0.05) were slightly higher in the PT group. The overall rate of revision surgery was 48.0% and 54.5% in the DT and PT groups, respectively (p = 0.629). The prevalence of PJK according to radiological criteria was 34% in the DT group and 27% in the PT group (p = 0.609). The percent of patients with PJK that required surgical correction (surgical PJK) was 11.9% (8 of 67) in the DT group and 9.1% (2 of 22) in the PT group (p = 1.0). The onset of surgical PJK was significantly earlier than radiological PJK in the DT group (p < 0.01). The types of PJK were different in the PT and DT groups. Compression fracture at the UIV was more prevalent in the DT group, whereas subluxation was more prevalent in the PT group. Postoperatively, the PT group had less thoracic kyphosis (p = 0.02), less sagittal imbalance (p < 0.01), and less pelvic tilt (p = 0.04). In the DT group, early postoperative radiographs demonstrated that the proximal junctional angle of patients with surgical PJK was greater than in those without PJK and those with radiological PJK (p < 0.01). Clinical outcomes were significantly improved in both groups, and there was no significant difference between the groups. Conclusions Both PT and DT UIVs improve segmental and global sagittal plane alignment as well as patient-reported quality of life in those treated for adult spinal deformity. The prevalence of PJK was not different in the PT and DT groups. However, compression fracture was the mechanism more frequently observed with DT PJK, and subluxation was the mechanism more frequently observed in PT PJK. Strategies to avoid PJK may include vertebral augmentation to prevent fracture at the DT spine and mechanical means to prevent vertebral subluxation at the PT spine.

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Selection of the Optimal Distal Fusion Level in Posterior Instrumentation and Fusion for Thoracic Hyperkyphosis: The Sagittal Stable Vertebra Concept

Cited by 18 publications

References 17 publications

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

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