Predicting development of severe clinically relevant distal junctional kyphosis following adult cervical deformity surgery, with further distinction from mild asymptomatic episodes

View More View Less
  • 1 Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;
  • | 2 Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;
  • | 3 Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, New York;
  • | 4 Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;
  • | 5 Department of Orthopedics, SUNY Downstate Medical Center, Brooklyn, New York;
  • | 6 Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California;
  • | 7 Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada;
  • | 8 Department of Orthopaedic Surgery, University of California, Davis, California;
  • | 9 Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, Washington;
  • | 10 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;
  • | 11 Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina;
  • | 12 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; and
  • | 13 Department of Neurological Surgery, University of California, San Francisco, California
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $45.00
USD  $376.00
USD  $612.00
Print or Print + Online Sign in

OBJECTIVE

This retrospective cohort study aimed to develop a formal predictive model distinguishing between symptomatic and asymptomatic distal junctional kyphosis (DJK). In this study the authors identified a DJK rate of 32.2%. Predictive models were created that can be used with high reliability to help distinguish between severe symptomatic DJK and mild asymptomatic DJK through the use of surgical factors, radiographic parameters, and patient variables.

METHODS

Patients with cervical deformity (CD) were stratified into asymptomatic and symptomatic DJK groups. Symptomatic: 1) DJK angle (DJKA) > 10° and either reoperation due to DJK or > 1 new-onset neurological sequela related to DJK; or 2) either a DJKA > 20° or ∆DJKA > 20°. Asymptomatic: ∆DJK > 10° in the absence of neurological sequelae. Stepwise logistic regressions were used to identify factors associated with these types of DJK. Decision tree analysis established cutoffs.

RESULTS

A total of 99 patients with CD were included, with 32.2% developing DJK (34.3% asymptomatic, 65.7% symptomatic). A total of 37.5% of asymptomatic patients received a reoperation versus 62.5% symptomatic patients. Multivariate analysis identified independent baseline factors for developing symptomatic DJK as follows: pelvic incidence (OR 1.02); preoperative cervical flexibility (OR 1.04); and combined approach (OR 6.2). Having abnormal hyperkyphosis in the thoracic spine, more so than abnormal cervical lordosis, was a factor for developing symptomatic disease when analyzed against asymptomatic patients (OR 1.2). Predictive modeling identified factors that were predictive of symptomatic versus no DJK, as follows: myelopathy (modified Japanese Orthopaedic Association score 12–14); combined approach; uppermost instrumented vertebra C3 or C4; preoperative hypermobility; and > 7 levels fused (area under the curve 0.89). A predictive model for symptomatic versus asymptomatic disease (area under the curve 0.85) included being frail, T1 slope minus cervical lordosis > 20°, and a pelvic incidence > 46.3°. Controlling for baseline deformity and disability, symptomatic patients had a greater cervical sagittal vertical axis (4–8 cm: 47.6% vs 27%) and were more malaligned according to their Scoliosis Research Society sagittal vertical axis measurement (OR 0.1) than patients without DJK at 1 year (all p < 0.05). Despite their symptomatology and higher reoperation rate, outcomes equilibrated in the symptomatic cohort at 1 year following revision.

CONCLUSIONS

Overall, 32.2% of patients with CD suffered from DJK. Symptomatic DJK can be predicted with high reliability. It can be further distinguished from asymptomatic occurrences by taking into account pelvic incidence and baseline cervicothoracic deformity severity.

ABBREVIATIONS

AUC = area under the curve; CBVA = chin-brow vertical angle; CD = cervical deformity; CL = cervical lordosis; cSVA = cervical SVA; DJK = distal junctional kyphosis; DJKA = DJK angle; EQ-5D = EuroQol-5D health survey; HRQOL = health-related quality of life; LIV = lowest instrumented vertebra; LL = lumbar lordosis; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PI = pelvic incidence; PI-LL = PI-LL mismatch; PJK = proximal junctional kyphosis; PT = pelvic tilt; SRS = Scoliosis Research Society; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis; TS−CL = T1 slope minus CL; UIV = uppermost instrumented vertebra; VAS = visual analog scale.

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $376.00
USD  $612.00
  • 1

    Smith JS, Line B, Bess S, Shaffrey CI, Kim HJ, Mundis G, et al. The Health Impact of Adult Cervical Deformity in Patients Presenting for Surgical Treatment: Comparison to United States Population Norms and Chronic Disease States Based on the EuroQuol-5 Dimensions Questionnaire. Neurosurgery. 2017;80(5):716725.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Passias PG, Soroceanu A, Smith J, Boniello A, Yang S, Scheer JK, et al. Postoperative cervical deformity in 215 thoracolumbar patients with adult spinal deformity: prevalence, risk factors, and impact on patient-reported outcome and satisfaction at 2-year follow-up. Spine (Phila Pa 1976).2015;40(5):283291.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Bogduk N. Functional anatomy of the spine. Handb Clin Neurol. 2016;136(675):688.

  • 4

    Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H. Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression. J Neurosurg Spine. 2009;11(5):521528.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Caruso L, Barone G, Farneti A, Caraffa A. Pedicle subtraction osteotomy for the treatment of chin-on-chest deformity in a post-radiotherapy dropped head syndrome: a case report and review of literature. Eur Spine J. 2014;23(suppl 6):634643.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Patel PD, Arutyunyan G, Plusch K, Vaccaro A Jr, Vaccaro AR. A review of cervical spine alignment in the normal and degenerative spine. J Spine Surg. 2020;6(1):106123.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Hills JM, Weisenthal B, Sivaganesan A, Bydon M, Archer KR, Devin CJ. Value based spine care: paying for outcomes, not volume. Semin Spine Surg. 2019;31(1):1219.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Lafage R, Schwab F, Glassman S, Bess S, Harris B, Sheer J, et al. Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976).2017;42(17):12751282.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Schwab FJ, Lafage R, Glassman SD, Bess S, Harris B, Sheer J, et al. Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976).2017;42(17):12751282.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Scheer JK, Fakurnejad S, Lau D, Daubs MD, Coe JD, Paonessa KJ, et al. Results of the 2014 SRS Survey on PJK/PJF: a report on variation of select SRS member practice patterns, treatment indications, and opinions on classification development. Spine (Phila Pa 1976).2015;40(11):829840.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Lowe TG, Lenke L, Betz R, Newton P, Clements D, Haher T, et al. Distal junctional kyphosis of adolescent idiopathic thoracic curves following anterior or posterior instrumented fusion: incidence, risk factors, and prevention. Spine (Phila Pa 1976).2006;31(3):299302.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Protopsaltis TS, Stekas N, Lafage R, Smith JS, Soroceaunu A, Sciubba DM, et al. Impact of adult deformity correction: 261. Can we define clinically relevant DJK in cervical deformity surgery? Spine J. 2018;18(8 Suppl):S129S130.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Protopsaltis TS, Ramchandran S, Kim HJ, et al. Analysis of early distal junctional kyphosis (DJK) after cervical deformity correction. Spine J. 2016;16(10):S355S356.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):12451251.

  • 15

    Miller EK, Neuman BJ, Jain A, Daniels AH, Ailon T, Sciubba DM, et al. An assessment of frailty as a tool for risk stratification in adult spinal deformity surgery. Neurosurg Focus. 2017;43(6):E3.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8 24.

  • 17

    Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409415.

  • 18

    Tetreault L, Kopjar B, Nouri A, Arnold P, Barbagallo G, Bartels R, et al. The modified Japanese Orthopaedic Association scale: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. Eur Spine J. 2017;26(1):7884.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Smith JS, Eastlack RK, Blaskiewicz DJ, Shaffrey CI, Schwab FJ, Bess S, et al. Reliability assessment of a novel cervical deformity classification system. In: International Meeting on Advanced Spine Techniques (IMAST). SRS;2014.Accessed September 30, 2021. https://www.srs.org/UserFiles/file/meetings/imast2014/IMAST14-Final-4web3.pdf

    • Search Google Scholar
    • Export Citation
  • 20

    Moses MJ, Tishelman JC, Zhou PL, Moon JY, Beaubrun BM, Buckland AJ, Protopsaltis TS. McGregor’s slope and slope of line of sight: two surrogate markers for chin-brow vertical angle in the setting of cervical spine pathology. Spine J. 2019;19(9):15121517.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ayres EW, Protopsaltis TS, Lafage R, et al. 298. Predicting the magnitude of distal junctional kyphosis following cervical deformity correction. Spine J. 2019;19(9):S145.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Blondel B, Lafage V, Farcy JPP, Schwab F, Bollini G, Jouve JLL. Influence of screw type on initial coronal and sagittal radiological correction with hybrid constructs in adolescent idiopathic scoliosis. Correction priorities. Orthop Traumatol Surg Res. 2012;98(8):873878.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Arbash MA, Parambathkandi AM, Baco AM, Alhammoud A. Impact of screw type on kyphotic deformity correction after spine fracture fixation: cannulated versus solid pedicle screw. Asian Spine J. 2018;12(6):10531059.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Lundine K, Turner P, Johnson M. Thoracic hyperkyphosis: assessment of the distal fusion level. Global Spine J. 2012;2(2):6570.

  • 25

    Liabaud B, Lafage R, Hart RA, Schwab FJ, Smith JS, Kim HJ, et al. Proximal junctional kyphosis (PJK) can be predicted following adult spinal deformity (ASD) surgery: models based on regional alignment changes within the fusion area. Spine J. 2016;16(10)(suppl):S132.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Passias PG, Vasquez-Montes D, Poorman GW, Protopsaltis T, Horn SR, Bortz CA, et al. Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J. 2018;18(12):21872194.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Passias PG, Horn SR, Oh C, Lafage R, Lafage V, Smith JS, et al. Predicting the occurrence of postoperative distal junctional kyphosis in cervical deformity patients. Neurosurgery. 2020;86(1):E38E46.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Kim HJ, Iyer S. Proximal junctional kyphosis. J Am Acad Orthop Surg. 2016;24(5):318326.

  • 29

    Bridwell KH, Lenke LG, Cho SK, Pahys JM, Zebala LP, Dorward IG, et al. Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery. 2013;72(6):899906.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 553 553 122
Full Text Views 110 110 42
PDF Downloads 166 166 82
EPUB Downloads 0 0 0