Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

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OBJECTIVE

The surgical correction of adult spinal deformity (ASD) often involves modifying lumbar lordosis (LL) to restore ideal sagittal alignment. However, corrections that include large changes in LL increase the risk for development of proximal junctional kyphosis (PJK). Little is known about the impact of cranial versus caudal correction in the lumbar spine on the occurrence of PJK. The goal of this study was to investigate the impact of the location of the correction on acute PJK development.

METHODS

This study was a retrospective review of a prospective multicenter database. Surgically treated ASD patients with early follow-up evaluations (6 weeks) and fusions of the full lumbosacral spine were included. Radiographic parameters analyzed included the classic spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], PI−LL, and sagittal vertical axis [SVA]) and segmental correction. Using Glattes’ criteria, patients were stratified into PJK and noPJK groups and propensity matched by age and regional lumbar correction (ΔPI−LL). Radiographic parameters and segmental correction were compared between PJK and noPJK patients using independent t-tests.

RESULTS

After propensity matching, 312 of 483 patients were included in the analysis (mean age 64 years, 76% women, 40% with PJK). There were no significant differences between PJK and noPJK patients at baseline or postoperatively, or between changes in alignment, with the exception of thoracic kyphosis (TK) and ΔTK. PJK patients had a decrease in segmental lordosis at L4-L5-S1 (−0.6° vs 1.6°, p = 0.025), and larger increases in segmental correction at cranial levels L1-L2-L3 (9.9° vs 7.1°), T12-L1-L2 (7.3° vs 5.4°), and T11-T12-L1 (2.9° vs 0.7°) (all p < 0.05).

CONCLUSIONS

Although achievement of an optimal sagittal alignment is the goal of realignment surgery, dramatic lumbar corrections appear to increase the risk of PJK. This study was the first to demonstrate that patients who developed PJK underwent kyphotic changes in the L4–S1 segments while restoring LL at more cranial levels (T12–L3). These findings suggest that restoring lordosis at lower lumbar levels may result in a decreased risk of developing PJK.

ABBREVIATIONS ASD = adult spinal deformity; FH = femoral head; HRQOL = health-related quality of life; LIV = lower instrumented vertebra; LL = lumbar lordosis; PI = pelvic incidence; PJK = proximal junctional kyphosis; PT = pelvic tilt; SVA = sagittal vertical axis; TK = thoracic kyphosis; TPA = T1−pelvic angle; UIV = upper instrumented vertebra.

Article Information

Correspondence Virginie Lafage: Hospital for Special Surgery, New York, NY. virginie.lafage@gmail.com.

INCLUDE WHEN CITING Published online October 26, 2018; DOI: 10.3171/2018.6.SPINE161468.

Disclosures The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes (current), NuVasive (current), K2M (current), Innovasis (past), Biomet (past), and individual donations. Dr. Obeid reports being a consultant for DePuy Synthes and Medtronic; receiving clinical or research support for the study from DePuy Synthes; and receiving royalties from Alphatec Spine, Spineart, and Clariance. Dr. Bess reports being a consultant for K2 and Allosource; receiving clinical or research support for the study from Biomet, DePuy Spine, and Innovasis; being a patent holder for K2; and receiving support of non–study-related clinical or research effort from Medtronic, Stryker, and NuVasive. Dr. Burton reports receiving royalties and research support of non–study-related clinical or research effort from DePuy. Dr. Smith reports being a consultant for Zimmer Biomet, NuVasive, and Cerapedics; receiving royalties from Zimmer Biomet; receiving support of non–study-related clinical or research effort from DePuy Synthes/ISSG; receiving clinical or research support for the study from DePuy Synthes/ISSG; receiving fellowship support from NREF and AO Spine; and receiving an honorarium for teaching from K2M. Dr. Hostin reports being a consultant for DePuy; and receiving support of non–study-related clinical or research effort from NuVasive, Seeger, DJO, DePuy, and K2M. Dr. Shaffrey reports being a consultant for Medtronic, NuVasive, Zimmer-Biomet, K2M, and Stryker; direct stock ownership of NuVasive; and being a patent holder and receiving royalties from Medtronic, NuVasive, and Zimmer-Biomet. Dr. Ames reports being a consultant for DePuy, Medtronic, and Stryker; being a patent holder for Fish & Richardson, P.C.; and receiving royalties from Stryker and Biomet Spine. Dr. Klineberg reports direct stock ownership in Nemaris, Inc.; being a consultant for NuVasive; receiving speaking/teaching arrangements from DePuy Spine, K2M, and MSD; and receiving support of non–study-related clinical or research effort from DePuy Spine, Stryker, NuVasive, and K2M (paid through ISSGF). Dr. Schwab reports direct stock ownership in Nemaris, Inc.; support of non–study-related clinical or research effort from DePuy Spine, NuVasive, Stryker, and K2M; and being a consultant for and receiving speaking/teaching arrangements from Zimmer-Biomet, Medicrea, MSD, K2M, and NuVasive. Dr. V. Lafage reports direct stock ownership in Nemaris, Inc.; being a consultant for NuVasive; receiving support of non–study-related clinical or research effort from DePuy Spine, K2M, Stryker, and NuVasive (paid through ISSGF); and speaking/teaching arrangements from DePuy Spine, NuVasive, MSD, and K2M.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Segmental change between 2 adjacent segments using L3-L2-L1 as an example. The change was calculated by subtracting the angle between L1-L2 and L2-L3 preoperatively (Pre) (black line vs light gray line) from L1-L2 and L2-L3 postoperatively (Post). If the difference is negative, the segmental change is kyphotic, otherwise it is a lordotic change.

  • View in gallery

    Segmental change (in degrees) within the lumbar spine according to LL correction group. No significant difference was found in segmental change at the lower part of the lordosis (FH-S1-L5) or at the thoracolumbar junction (L1-T12-T11). FH = femoral head. Figure is available in color online only.

  • View in gallery

    Distribution of age (in years), preoperative TPA (in degrees), and change (in degrees) in LL between PJK and noPJK after a propensity match. yo = years old. Figure is available in color online only.

  • View in gallery

    Comparison of segmental changes (in degrees) between PJK and noPJK. PJK patients experienced a significantly larger lordotic change in the upper part of the lumbar spine and a significantly more kyphotic change at the 2 UIV areas (T10 and T4). An asterisk denotes a significant difference between PJK and noPJK patients (p < 0.05). Figure is available in color online only.

  • View in gallery

    Comparison of the segmental correction (in degrees) between PJK and noPJK after substratification by UIV position. PJK patients experienced a larger lordotic change in the proximal lumbar levels (correction) associated with a kyphotic change at the UIV area (PJK). An asterisk denotes a significant difference between PJK and noPJK patients (p < 0.05). Figure is available in color online only.

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