Paraspinal muscle size as an independent risk factor for proximal junctional kyphosis in patients undergoing thoracolumbar fusion

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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OBJECTIVE

Proximal junctional kyphosis (PJK) is a structural complication of spinal fusion in 5%–61% of patients treated for adult spinal deformity. In nearly one-third of these cases, PJK is progressive and requires costly surgical revision. Previous studies have suggested that patient body habitus may predict risk for PJK. Here, the authors sought to investigate abdominal girth and paraspinal muscle size as risk factors for PJK.

METHODS

All patients undergoing thoracolumbosacral fusion greater than 2 levels at a single institution over a 5-year period with ≥ 6 months of radiographic follow-up were considered for inclusion. PJK was defined as kyphosis ≥ 20° between the upper instrumented vertebra (UIV) and two supra-adjacent vertebrae. Operative and radiographic parameters were recorded, including pre- and postoperative sagittal vertical axis (SVA), sacral slope (SS), lumbar lordosis (LL), pelvic tilt, pelvic incidence (PI), and absolute value of the pelvic incidence–lumbar lordosis mismatch (|PI-LL|), as well as changes in LL, |PI-LL|, and SVA. The authors also considered relative abdominal girth and the size of the paraspinal muscles at the UIV.

RESULTS

One hundred sixty-nine patients met inclusion criteria. On univariate analysis, PJK was associated with a larger preoperative SVA (p < 0.001) and |PI-LL| (p = 0.01), and smaller SS (p = 0.004) and LL (p = 0.001). PJK was also associated with more positive postoperative SVA (p = 0.01), ΔSVA (p = 0.01), Δ|PI-LL| (p < 0.001), and ΔLL (p < 0.001); longer construct length (p = 0.005); larger abdominal girth–to-muscle ratio (p = 0.007); and smaller paraspinal muscles at the UIV (p < 0.001). Higher postoperative SVA (OR 1.1 per cm), smaller paraspinal muscles at the UIV (OR 2.11), and more aggressive reduction in |PI-LL| (OR 1.03) were independent predictors of radiographic PJK on multivariate logistic regression.

CONCLUSIONS

A more positive postoperative global sagittal alignment and smaller paraspinal musculature at the UIV most strongly predicted PJK following thoracolumbosacral fusion.

ABBREVIATIONS AP = anteroposterior; BMD = bone mineral density; BMP = bone morphogenetic protein; CCI = Charlson Comorbidity Index; DEXA = dual energy x-ray absorptiometry; LL = lumbar lordosis; |PI-LL| = absolute value of PI-LL mismatch; PJK = proximal junctional kyphosis; ROC = receiver operating characteristic; SS = sacral slope; SVA = sagittal vertical axis; UIV = upper instrumented vertebra.

Article Information

Correspondence Daniel M. Sciubba: Johns Hopkins School of Medicine, Baltimore, MD. dsciubb1@jhmi.edu.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.SPINE19108.

Disclosures Dr. Passias: consultant for Medicrea and SpineWave; teaching and speaking honoraria from Zimmer Biomet; scientific advisory board for Allosource; funding from Medicrea, SpineWave, Allosource, Zimmer Biomet, Globus, Cervical Spine Research Society, and Aesculap; and clinical or research support for this study from Aesculap. Dr. Protopsaltis: consultant for Medicrea, NuVasive, Globus, K2M, and Innovasis; direct stock ownership in Torus Medical; and research support from Zimmer Spine and the Cervical Spine Research Society. Dr. Neuman: research grant from DePuy-Synthes for this study and lecture speaker for Medtronic. Dr. Kebaish: consultant for DePuy-Synthes and K2M, royalties from DePuy-Synthes and Orthofix, and honoraria from K2M. Dr. Goodwin: consultant for ROM3 Rehab and Augmedics, and royalties from Kendall Hunt Publishing. Dr. Sciubba: consultant for Baxter, DePuy-Synthes, Globus, K2M, Medtronic, NuVasive, Stryker.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    ROC curve for multivariate model of radiographic proximal junctional kyphosis ≥ 20°. Figure is available in color online only.

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    ROC curve for multivariate model of symptomatic proximal junctional kyphosis ≥ 20°. Figure is available in color online only.

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