Two different types of postoperative sagittal imbalance after long instrumented fusion to the sacrum for degenerative sagittal imbalance

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  • 1 Department of Orthopedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul;
  • 2 Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
  • 3 Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
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OBJECTIVE

Few studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI).

METHODS

Eighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared.

RESULTS

Forty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group.

CONCLUSIONS

Optimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

ABBREVIATIONS ASD = adult spinal deformity; CSA = cross-sectional area; DSI = degenerative sagittal imbalance; LL = lumbar lordosis; ODI = Oswestry Disability Index; PI = pelvic incidence; PJA = proximal junctional angle; PJF = proximal junctional failure; PJK = proximal junctional kyphosis; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis; UIV = upper instrumented vertebra; VAS = visual analog scale.

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Contributor Notes

Correspondence Kee-Yong Ha: College of Medicine, Kyung Hee University, Seoul, South Korea. kyh@catholic.ac.kr.

INCLUDE WHEN CITING Published online June 26, 2020; DOI: 10.3171/2020.4.SPINE20153.

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

    Glassman SD, Bridwell K, Dimar JR, The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):20242029.

    • Search Google Scholar
    • Export Citation
  • 2

    Lafage V, Schwab F, Patel A, Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599E606.

    • Search Google Scholar
    • Export Citation
  • 3

    Chang DG, Ha KY, Kim YH, Lee EW. Spinopelvic alignment by different surgical methods in the treatment of degenerative sagittal imbalance of the lumbar spine. Clin Spine Surg. 2017;30(4):E390E397.

    • Search Google Scholar
    • Export Citation
  • 4

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

  • 5

    Glattes RC, Bridwell KH, Lenke LG, Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976). 2005;30(14):16431649.

    • Search Google Scholar
    • Export Citation
  • 6

    Hassanzadeh H, Gupta S, Jain A, Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform. 2013;1(4):299305.

    • Search Google Scholar
    • Export Citation
  • 7

    Kim HJ, Bridwell KH, Lenke LG, Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976). 2013;38(11):896901.

    • Search Google Scholar
    • Export Citation
  • 8

    Kim YJ, Bridwell KH, Lenke LG, Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976). 2008;33(20):21792184.

    • Search Google Scholar
    • Export Citation
  • 9

    Lau D, Clark AJ, Scheer JK, 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
  • 10

    Lee JH, Kim JU, Jang JS, Lee SH. Analysis of the incidence and risk factors for the progression of proximal junctional kyphosis following surgical treatment for lumbar degenerative kyphosis: minimum 2-year follow-up. Br J Neurosurg. 2014;28(2):252258.

    • Search Google Scholar
    • Export Citation
  • 11

    Yagi M, Rahm M, Gaines R, 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
  • 12

    Berjano P, Bassani R, Casero G, Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J. 2013;22(suppl 6):S853S858.

    • Search Google Scholar
    • Export Citation
  • 13

    Cho KJ, Suk SI, Park SR, Risk factors of sagittal decompensation after long posterior instrumentation and fusion for degenerative lumbar scoliosis. Spine (Phila Pa 1976). 2010;35(17):15951601.

    • Search Google Scholar
    • Export Citation
  • 14

    Kuhns CA, Bridwell KH, Lenke LG, Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up. Spine (Phila Pa 1976). 2007;32(24):27712776.

    • Search Google Scholar
    • Export Citation
  • 15

    Lee CS, Lee CK, Kim YT, Dynamic sagittal imbalance of the spine in degenerative flat back: significance of pelvic tilt in surgical treatment. Spine (Phila Pa 1976). 2001;26(18):20292035.

    • Search Google Scholar
    • Export Citation
  • 16

    Arima H, Yamato Y, Hasegawa T, Discrepancy between standing posture and sagittal balance during walking in adult spinal deformity patients. Spine (Phila Pa 1976). 2017;42(1):E25E30.

    • Search Google Scholar
    • Export Citation
  • 17

    Son SM, Shin JK, Goh TS, Predictive findings of the presence of stooping in patients with lumbar degenerative kyphosis by upright whole spine lateral radiography. Spine (Phila Pa 1976). 2018;43(8):571577.

    • Search Google Scholar
    • Export Citation
  • 18

    Moon MS, Lee H, Kim ST, Spinopelvic orientation on radiographs in various body postures: upright standing, chair sitting, Japanese style kneel sitting, and Korean style cross-legged sitting. Clin Orthop Surg. 2018;10(3):322327.

    • Search Google Scholar
    • Export Citation
  • 19

    Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976). 2009;34(17):18281833.

    • Search Google Scholar
    • Export Citation
  • 20

    Schwab F, Patel A, Ungar B, Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010;35(25):22242231.

    • Search Google Scholar
    • Export Citation
  • 21

    Ntilikina Y, Bahlau D, Garnon J, Open versus percutaneous instrumentation in thoracolumbar fractures: magnetic resonance imaging comparison of paravertebral muscles after implant removal. J Neurosurg Spine. 2017;27(2):235241.

    • Search Google Scholar
    • Export Citation
  • 22

    Käser L, Mannion AF, Rhyner A, Active therapy for chronic low back pain: part 2. Effects on paraspinal muscle cross-sectional area, fiber type size, and distribution. Spine (Phila Pa 1976). 2001;26(8):909919.

    • Search Google Scholar
    • Export Citation
  • 23

    Marras WS, Jorgensen MJ, Granata KP, Wiand B. Female and male trunk geometry: size and prediction of the spine loading trunk muscles derived from MRI. Clin Biomech (Bristol, Avon). 2001;16(1):3846.

    • Search Google Scholar
    • Export Citation
  • 24

    Hyun SJ, Bae CW, Lee SH, Rhim SC. Fatty degeneration of the paraspinal muscle in patients with degenerative lumbar kyphosis: a new evaluation method of quantitative digital analysis using MRI and CT scan. Clin Spine Surg. 2016;29(10):441447.

    • Search Google Scholar
    • Export Citation
  • 25

    Kim CY, Lee SM, Lim SA, Choi YS. Impact of fat infiltration in cervical extensor muscles on cervical lordosis and neck pain: a cross-sectional study. Clin Orthop Surg. 2018;10(2):197203.

    • Search Google Scholar
    • Export Citation
  • 26

    Pfirrmann CW, Metzdorf A, Zanetti M, Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2001;26(17):18731878.

    • Search Google Scholar
    • Export Citation
  • 27

    Cho KJ, Kim KT, Kim WJ, Pedicle subtraction osteotomy in elderly patients with degenerative sagittal imbalance. Spine (Phila Pa 1976). 2013;38(24):E1561E1566.

    • Search Google Scholar
    • Export Citation
  • 28

    Sebaaly A, Sylvestre C, El Quehtani Y, Incidence and risk factors for proximal junctional kyphosis: results of a multicentric study of adult scoliosis. Clin Spine Surg. 2018;31(3):E178E183.

    • Search Google Scholar
    • Export Citation
  • 29

    Ha KY, Kim SI, Kim YH, Jack-knife posture after correction surgery for degenerative sagittal imbalance—does spinopelvic parameter always matter in preventing stooping posture? Spine Deform. 2018;6(6):771780.

    • Search Google Scholar
    • Export Citation
  • 30

    Lee JH, Lee SH. Does lumbar paraspinal muscles improve after corrective fusion surgery in degenerative flat black? Indian J Orthop. 2017;51(2):147154.

    • Search Google Scholar
    • Export Citation
  • 31

    Yagi M, King AB, Boachie-Adjei O. Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976). 2012;37(17):14791489.

    • Search Google Scholar
    • Export Citation

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