Surgical outcomes for late neurological deficits after long segment instrumentation for degenerative adult spinal deformity

View More View Less
  • 1 Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul;
  • | 2 Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do;
  • | 3 Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
  • | 4 Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00
Print or Print + Online

OBJECTIVE

The most catastrophic symptom of proximal junctional failure (PJF) following long instrumented fusion surgery for adult spinal deformity (ASD) is neurological deficits. Although previous reports have shown that PJF usually developed during the early postoperative period, some patients showed late neurological deficits. The aim of this study was to report the incidence, characteristics, and surgical outcomes of PJF with late neurological deficits.

METHODS

Patients surgically treated for ASD at a single institution were retrospectively reviewed. Among them, the patients requiring revision surgery for newly developed neurological deficits at least 6 months after the initial surgery were included. Patient demographic, radiographic, surgical, and clinical data were investigated. Neurological status was assessed using the Frankel grading system.

RESULTS

PJF with late neurological deficits developed in 18 of 385 patients (4.7%). The mean age at the onset of neurological deficits was 72.0 ± 6.0 years, and the median time from the initial surgery was 4.5 years. The most common pathology of PJF was adjacent disc degeneration and subsequent canal stenosis (11 patients). Five patients showed disc degeneration with aseptic bone destruction. Fractures at the upper instrumented vertebra (UIV), UIV + 1, and UIV + 2 occurred in 2, 3, and 2 patients, respectively. Ossification of the yellow ligament, which had not been found at the first surgery, was identified in 6 patients. Eight patients showed improvement of their neurological deficits and 10 patients showed no improvement by the final follow-up. Perioperative major complications occurred in 8 of 18 patients.

CONCLUSIONS

The incidence of PJF with late neurological deficits following ASD surgery was 4.7% in this cohort. The patients showed several morphological features. After revision surgery, perioperative complications were common and the prognosis for improved neurological status was not favorable.

ABBREVIATIONS

ASD = adult spinal deformity; BMI = body mass index; CCI = Charlson Comorbidity Index; LIV = lower instrumented vertebra; OYL = ossification of the yellow ligament; PJF = proximal junctional failure; PJK = proximal junctional kyphosis; PSO = pedicle subtraction osteotomy; SVA = sagittal vertical axis; TLJ = thoracolumbar junction; UIV = upper instrumented vertebra.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00

Contributor Notes

Correspondence Sang-Il Kim: Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. sang1kim81@gmail.com.

INCLUDE WHEN CITING Published online July 9, 2021; DOI: 10.3171/2020.12.SPINE20604.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Kim HJ, Yang JH, Chang DG, et al. . Adult spinal deformity: current concepts and decision-making strategies for management. Asian Spine J. 2020;14(6):886897.

    • Search Google Scholar
    • Export Citation
  • 2

    Ignasiak D, Peteler T, Fekete TF, et al. . The influence of spinal fusion length on proximal junction biomechanics: a parametric computational study. Eur Spine J. 2018;27(9):22622271.

    • Search Google Scholar
    • Export Citation
  • 3

    Arlet V, Aebi M. Junctional spinal disorders in operated adult spinal deformities: present understanding and future perspectives. Eur Spine J. 2013;22(suppl 2):S276S295.

    • Search Google Scholar
    • Export Citation
  • 4

    Lau D, Clark AJ, Scheer JK, et al. . Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976 ).2014;39(25):20932102.

    • Search Google Scholar
    • Export Citation
  • 5

    Segreto FA, Passias PG, Lafage R, et al. . Incidence of acute, progressive, and delayed proximal junctional kyphosis over an 8-year period in adult spinal deformity patients. Oper Neurosurg (Hagerstown). 2020;18(1):7582.

    • Search Google Scholar
    • Export Citation
  • 6

    Lee J, Park YS. Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment. Asian Spine J. 2016;10(3):593600.

  • 7

    Koike Y, Kotani Y, Terao H, Iwasaki N. Risk factor analysis of proximal junctional kyphosis after surgical treatment of adult spinal deformity with oblique lateral interbody fusion. Asian Spine J. 2021;15(1):107116.

    • Search Google Scholar
    • Export Citation
  • 8

    Hostin R, McCarthy I, OʼBrien M, et al. . Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976 ).2013;38(12):10081015.

    • Search Google Scholar
    • Export Citation
  • 9

    O’Leary PT, Bridwell KH, Lenke LG, et al. . Risk factors and outcomes for catastrophic failures at the top of long pedicle screw constructs: a matched cohort analysis performed at a single center. Spine (Phila Pa 1976 ).2009;34(20):21342139.

    • Search Google Scholar
    • Export Citation
  • 10

    Yagi M, Rahm M, Gaines R, et al. . Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity. Spine (Phila Pa 1976 ).2014;39(10):E607E614.

    • Search Google Scholar
    • Export Citation
  • 11

    Yang J, Khalifé M, Lafage R, et al. . What factors predict the risk of proximal junctional failure in the long term, demographic, surgical, or radiographic?: results from a time-dependent ROC curve. Spine (Phila Pa 1976 ).2019;44(11):777784.

    • Search Google Scholar
    • Export Citation
  • 12

    Park SJ, Lee CS, Chung SS, et al. . Different risk factors of proximal junctional kyphosis and proximal junctional failure following long instrumented fusion to the sacrum for adult spinal deformity: survivorship analysis of 160 patients. Neurosurgery. 2017;80(2):279286.

    • Search Google Scholar
    • Export Citation
  • 13

    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373383.

    • Search Google Scholar
    • Export Citation
  • 14

    Smith MW, Annis P, Lawrence BD, et al. . Acute proximal junctional failure in patients with preoperative sagittal imbalance. Spine J. 2015;15(10):21422148.

    • Search Google Scholar
    • Export Citation
  • 15

    Scheer JK, Fakurnejad S, Lau D, 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.

    • Search Google Scholar
    • Export Citation
  • 16

    Smith JS, Klineberg E, Lafage V, et al. . Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine. 2016;25(1):114.

    • Search Google Scholar
    • Export Citation
  • 17

    Scheer JK, Osorio JA, Smith JS, et al. . Development of validated computer-based preoperative predictive model for proximal junction failure (PJF) or clinically significant PJK with 86% accuracy based on 510 ASD patients with 2-year follow-up. Spine (Phila Pa 1976 ).2016;41(22):E1328E1335.

    • Search Google Scholar
    • Export Citation
  • 18

    Ha KY, Seo JY, Son IN, et al. . Thoracic myelopathy caused by ossification of the yellow ligament in patients with posterior instrumented lumbar fusion. Eur Spine J. 2012;21(12):24432449.

    • Search Google Scholar
    • Export Citation
  • 19

    Kasukawa Y, Miyakoshi N, Hongo M, et al. . Surgical results of patients with myelopathy due to ossification of the ligamentum flavum with ossification of the posterior longitudinal ligament or a vertebral fracture at the same level of the thoracic spine: a retrospective comparative study. Asian Spine J. 2019;13(5):832841.

    • Search Google Scholar
    • Export Citation
  • 20

    Kim SI, Ha KY, Lee JW, Kim YH. Prevalence and related clinical factors of thoracic ossification of the ligamentum flavum-a computed tomography-based cross-sectional study. Spine J. 2018;18(4):551557.

    • Search Google Scholar
    • Export Citation
  • 21

    Tsukamoto N, Maeda T, Miura H, et al. . Repetitive tensile stress to rat caudal vertebrae inducing cartilage formation in the spinal ligaments: a possible role of mechanical stress in the development of ossification of the spinal ligaments. J Neurosurg Spine. 2006;5(3):234242.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 147 147 147
Full Text Views 31 31 31
PDF Downloads 32 32 32
EPUB Downloads 0 0 0