Upper Thoracic versus Lower Thoracic as Site of Upper Instrumented Vertebrae for Long Fusion Surgery in Adult Spinal Deformity: A Meta-Analysis of Proximal Junctional Kyphosis

Luo, Ming; Wang, Pu; Wang, Wengang; Shen, Mingkui; Xu, Genzhong; Xia, Lei

doi:10.1016/j.wneu.2017.02.126

Cited by 24 publications

(12 citation statements)

References 37 publications

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“…1 Excessive kyphosis through the uninstrumented thoracic spine can increase anterior compressive forces at the UIV and the adjacent vertebra above the UIV (UIV þ 1), which is a contributor to the development of proximal junctional kyphosis/ failure (PJK/PJF) and often leads to high revision rates. [2][3][4][5][6] A plethora of literature exists on the clinical and radiographic risk factors for PJK. 3,[7][8][9][10][11][12][13][14][15][16][17][18] However, prevention of PJK remains unsolved and is still a relatively common postoperative complication.…”

Section: Introductionmentioning

confidence: 99%

Can Machine Learning Accurately Predict Postoperative Compensation for the Uninstrumented Thoracic Spine and Pelvis After Fusion From the Lower Thoracic Spine to the Sacrum?

Lee

Sardar

Boddapati

et al. 2020

Global Spine Journal

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Study Design: Consecutively collected cases. Objective: To determine if a machine-learning (ML) program can accurately predict the postoperative thoracic kyphosis through the uninstrumented thoracic spine and pelvic compensation in patients who undergo fusion from the lower thoracic spine (T10 or T11) to the sacrum. Methods: From 2015 to 2019, a consecutive series of adult (≥18 years old) patients with adult spinal deformity underwent corrective spinal fusion from the lower thoracic spine (T10 or T11) to the sacrum. Deidentified data was processed by a ML system-based platform to predict the postoperative thoracic kyphosis (TK) and pelvic tilt (PT) for each patient. To validate the ML model, the postoperative TK (T4-T12, instrumented thoracic, and uninstrumented thoracic) and the pelvic tilt were compared against the predicted values. Results: A total of 20 adult patients with a minimum 6-month follow-up (mean: 22.4 ± 11.3 months) were included in this study. No significant differences were observed for TK (predicted 37.6° vs postoperative 38.3°, P = .847), uninstrumented TK (predicted 33.9° vs postoperative 29.8°, P = .188), and PT (predicted 23.4° vs postoperative 22.7°, P = .754). The predicted PT and the TK of the uninstrumented thoracic spine correlated well with postoperative values (uninstrumented TK: R 2 = 0.764, P < .001; PT: R 2 = 0.868, P < .001). The mean error with which kyphosis through the uninstrumented thoracic spine can be measured was 4.8° ± 4.0°. The mean error for predicting PT was 2.5° ± 1.7°. Conclusion: ML algorithms can accurately predict the spinopelvic compensation after spinal fusion from the lower thoracic spine to the sacrum. These findings suggest that surgeons may be able to leverage this technology to reduce the risk of proximal junctional kyphosis in this population.

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Section: Introductionmentioning

confidence: 99%

Can Machine Learning Accurately Predict Postoperative Compensation for the Uninstrumented Thoracic Spine and Pelvis After Fusion From the Lower Thoracic Spine to the Sacrum?

Lee

Sardar

Boddapati

et al. 2020

Global Spine Journal

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“…3,9,19,21,22 Some complications, such as proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), have been previously associated with choice of upper instrumented vertebra (UIV) level. 1,5,10,13 However, despite an early understanding of appropriate patient selection metrics as well as expected outcomes following ASD surgery, 4,15,17,23,24 there is no clear consensus as to which patient demographic, radiographic, and clinical factors should be used to determine whether to fuse to the lower-thoracic (LT) versus upper-thoracic (UT) spine.…”

mentioning

confidence: 99%

Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes

Daniels

Reid

Durand

et al. 2020

Journal of Neurosurgery: Spine

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OBJECTIVEOptimal patient selection for upper-thoracic (UT) versus lower-thoracic (LT) fusion during adult spinal deformity (ASD) correction is challenging. Radiographic and clinical outcomes following UT versus LT fusion remain incompletely understood. The purposes of this study were: 1) to evaluate demographic, radiographic, and surgical characteristics associated with choice of UT versus LT fusion endpoint; and 2) to evaluate differences in radiographic, clinical, and health-related quality of life (HRQOL) outcomes following UT versus LT fusion for ASD.METHODSRetrospective review of a prospectively collected multicenter ASD database was performed. Patients with ASD who underwent fusion from the sacrum/ilium to the LT (T9–L1) or UT (T1–6) spine were compared for demographic, radiographic, and surgical characteristics. Outcomes including proximal junctional kyphosis (PJK), reoperation, rod fracture, pseudarthrosis, overall complications, 2-year change in alignment parameters, and 2-year HRQOL metrics (Lumbar Stiffness Disability Index, Scoliosis Research Society-22r questionnaire, Oswestry Disability Index) were compared after controlling for confounding factors via multivariate analysis.RESULTSThree hundred three patients (169 LT, 134 UT) were evaluated. Independent predictors of UT fusion included greater thoracic kyphosis (odds ratio [OR] 0.97 per degree, p = 0.0098), greater coronal Cobb angle (OR 1.06 per degree, p < 0.0001), and performance of a 3-column osteotomy (3-CO; OR 2.39, p = 0.0351). While associated with longer operative times (ratio 1.13, p < 0.0001) and greater estimated blood loss (ratio 1.31, p = 0.0018), UT fusions resulted in greater sagittal vertical axis improvement (−59.5 vs −41.0 mm, p = 0.0035) and lower PJK rates (OR 0.49, p = 0.0457). No significant differences in postoperative HRQOL measures, reoperation, or overall complication rates were detected between groups (all p > 0.1).CONCLUSIONSGreater deformity and need for 3-CO increased the likelihood of UT fusion. Despite longer operative times and greater blood loss, UT fusions resulted in better sagittal correction and lower 2-year PJK rates following surgery for ASD. While continued surveillance is necessary, this information may inform patient counseling and surgical decision-making.

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“…Constructs with extension into the UT spine have been associated with greater amounts of spinal alignment correction and reduced rates of PJK in ASD patients. 18,19 A common postoperative complaint among patients with a UT UIV is the presence of persistent scapular pain. While studies exist investigating persistent local pain following cervical spine surgery, [20][21][22][23][24][25] there is a lack of similar studies investigating chronic scapular pain following the extension of long constructs into the UT spine.…”

Section: Discussionmentioning

confidence: 99%

“…17,18 UIV placement in the upper thoracic (UT) spine (T1-6) has been associated with an increased degree of correction and reduced rates of proximal junctional kyphosis (PJK) relative to those in the lower thoracic (LT) spine (T7-12). 18,19 However, UT UIVs are also associated with longer operative times and increased operative blood loss. 17,18 Long-term HRQoL measures are not significantly different in patients with UIVs in the UT vs. those in the LT. 18 Anecdotally, however, many patients with UT UIV complain of chronic scapular pain following surgery.…”

Section: Introductionmentioning

confidence: 99%

Incidence of Chronic Periscapular Pain After Adult Thoracolumbar Deformity Correction and Impact on Outcomes

et al. 2021

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Objective: Extension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.Methods: ASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.Results: A total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.Conclusion: A UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.

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Upper Thoracic versus Lower Thoracic as Site of Upper Instrumented Vertebrae for Long Fusion Surgery in Adult Spinal Deformity: A Meta-Analysis of Proximal Junctional Kyphosis

Cited by 24 publications

References 37 publications

Can Machine Learning Accurately Predict Postoperative Compensation for the Uninstrumented Thoracic Spine and Pelvis After Fusion From the Lower Thoracic Spine to the Sacrum?

Can Machine Learning Accurately Predict Postoperative Compensation for the Uninstrumented Thoracic Spine and Pelvis After Fusion From the Lower Thoracic Spine to the Sacrum?

Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes

Incidence of Chronic Periscapular Pain After Adult Thoracolumbar Deformity Correction and Impact on Outcomes

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