Timing of conversion to cervical malalignment and proximal junctional kyphosis following surgical correction of adult spinal deformity: a 3-year radiographic analysis

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  • 1 Division of Spinal Surgery/Departments of Orthopedic Surgery and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York;
  • 2 Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;
  • 3 Department of Neurological Surgery, University of California, San Francisco;
  • 4 Department of Orthopaedic Surgery, University of California, Davis, California;
  • 5 Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;
  • 6 SUNY Downstate Medical Center/University Hospital Brooklyn, New York, New York;
  • 7 Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado;
  • 8 Department of Neurosurgery, University of Pittsburgh, Pennsylvania;
  • 9 Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri;
  • 10 Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan;
  • 11 Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado;
  • 12 Department of Neurosurgery and Orthopaedic Surgery, Duke Health, Durham, North Carolina; and
  • 13 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
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OBJECTIVE

The goal of this study was to assess the conversion rate from baseline cervical alignment to postoperative cervical deformity (CD) and the corresponding proximal junctional kyphosis (PJK) rate in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery.

METHODS

The operative records of patients with ASD with complete radiographic data beginning at baseline up to 3 years were included. Patients with no baseline CD were postoperatively stratified by Ames CD criteria (T1 slope–cervical lordosis mismatch [TS-CL] > 20°, cervical sagittal vertical axis [cSVA] > 40 mm), where CD was defined as fulfilling one or more of the Ames criteria. Severe CD was defined as TS-CL > 30° or cSVA > 60 mm. Follow-up intervals were established after ASD surgery, with 6 weeks postoperatively defined as early; 6 weeks–1 year as intermediate; 1–2 years as late; and 2–3 years as long-term. Descriptive analyses and McNemar tests identified the CD conversion rate, PJK rate (< −10° change in uppermost instrumented vertebra and the superior endplate of the vertebra 2 levels superior to the uppermost instrumented vertebra), and specific alignment parameters that converted.

RESULTS

Two hundred sixty-six patients who underwent ASD surgery (mean age 59.7 years, 77.4% female) met the inclusion criteria; 103 of these converted postoperatively, and the remaining 163 did not meet conversion criteria. Thirty-eight patients converted to CD early, 26 converted at the intermediate time point, 29 converted late, and 10 converted in the long-term. At conversion, the early group had the highest mean TS-CL at 25.4° ± 8.5° and the highest mean cSVA at 33.6 mm—both higher than any other conversion group. The long-term group had the highest mean C2–7 angle at 19.7° and the highest rate of PJK compared to other groups (p = 0.180). The early group had the highest rate of conversion to severe CD, with 9 of 38 patients having severe TS-CL and only 1 patient per group converting to severe cSVA. Seven patients progressed from having only malaligned TS-CL at baseline (with normal cSVA) to CD with both malaligned TS-CL and cSVA by 6 weeks. Conversely, only 2 patients progressed from malaligned cSVA to both malaligned cSVA and TS-CL. By 1 year, the former number increased from 7 to 26 patients, and the latter increased from 2 to 20 patients. The revision rate was highest in the intermediate group at 48.0%, versus the early group at 19.2%, late group at 27.3%, and long-term group at 20% (p = 0.128). A higher pelvic incidence–lumbar lordosis mismatch, lower thoracic kyphosis, and a higher thoracic kyphosis apex immediately postoperatively significantly predicted earlier rather than later conversion (all p < 0.05). Baseline lumbar lordosis, pelvic tilt, and sacral slope were not significant predictors.

CONCLUSIONS

Patients with ASD with normative cervical alignment who converted to CD after thoracolumbar surgery had varying radiographic findings based on timing of conversion. Although the highest number of patients converted within 6 weeks postoperatively, patients who converted in the late or long-term follow-up intervals had higher rates of concurrent PJK and greater radiographic progression.

ABBREVIATIONS ASD = adult spinal deformity; BMI = body mass index; CCI = Charlson Comorbidity Index; CD = cervical deformity; CL = cervical lordosis; cSVA = cervical SVA; LL = lumbar lordosis; ODI = Oswestry Disability Index; PI = pelvic incidence; PJK = proximal junctional kyphosis; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SRS-22 = 22-Item Scoliosis Research Society outcomes questionnaire; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis; TL = thoracolumbar; TS = T1 slope; UIV = uppermost instrumented vertebra.

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Contributor Notes

Correspondence Peter Passias: NYU Langone Medical Center, New York Spine Institute, New York, NY. peter.passias@nyumc.org.

INCLUDE WHEN CITING Published online March 19, 2021; DOI: 10.3171/2020.8.SPINE20320.

Disclosures Peter Passias: SpineWave, Medicrea, Terumo: consultant; Globus Medical, Zimmer: speaker’s bureau; Cervical Scoliosis Research Society: research support; AlloSource: other financial or material support. Han Jo Kim: AAOS, AO Spine: board or committee member, fellowship support; Cervical Spine Research Society: board or committee member; HSS Journal, Asian Spine Journal: editorial or governing board; ISSGF: research support; K2M: IP royalties; Scoliosis Research Society: board or committee member; Zimmer: IP royalties. Renaud Lafage: Nemaris: stock or stock options. Christopher Ames: Biomet Spine: IP royalties; Biomet Zimmer Spine: paid consultant; DePuy, a Johnson & Johnson Company: IP royalties, paid consultant, research support; Global Spine Analytics: director, other financial or material support; International Spine Study Group (ISSG): research support, executive committee, other financial or material support; K2M: IP royalties, paid consultant; Medicrea: IP royalties, paid consultant; Medtronic: paid consultant; Next Orthosurgical: IP royalties; NuVasive: IP royalties; Operative Neurosurgery: editorial board, other financial or material support; Scoliosis Research Society (SRS): grant funding, other financial or material support; Stryker: IP royalties, paid consultant; Titan Spine: research support. Eric Klineberg: AO Spine: paid presenter or speaker, research support; DePuy, a Johnson & Johnson Company, Medtronic/Medicrea, Stryker: paid consultant. Douglas Burton: Bioventus: research support; DePuy, a Johnson & Johnson Company: IP royalties, paid consultant, research support; Pfizer: research support; Progenerative Medical: stock or stock options; Scoliosis Research Society: board or committee member; Spine Deformity: editorial or governing board. Shay Bess: Mirus, Stryker: consultant; Progenerative Medicine, Carlsmed: direct stock ownership; DePuy Synthes, Stryker, NuVasive: clinical or research support for study described; DePuy Synthes, Globus, Medtronic, SI bone, ISSGF: support of non–study-related clinical or research effort overseen by the author; NuVasive, Stryker: royalties. Munish Gupta (for the past 12 months): DePuy, a Johnson & Johnson Company: IP royalties, paid consultant, travel paid for faculty and/or meetings; Innomed: IP royalties; Medtronic: paid consultant, travel paid for faculty and/or meetings; SRS: travel; Globus: paid consultant, royalties, travel paid for faculty and/or meetings; AO Spine: travel paid for faculty and/or meetings; Mizuho, Medicrea: other financial support. Paul Park: AANS Spine Section: board or committee member; AlloSource: paid consultant; Globus Medical: IP royalties, paid consultant; Journal of Neurosurgery: Spine, Neurosurgery, Operative Neurosurgery, The Spine Journal: editorial or governing board; Medtronic: paid consultant; North American Spine Society: board or committee member; NuVasive: paid consultant; Pfizer: research support; Scoliosis Research Society: board or committee member; Vertex: research support. Breton Line: ISSGF: paid consultant. Christopher I. Shaffrey: AANS: board or committee member; Cervical Spine Research Society: board or committee member; DePuy, a Johnson & Johnson Company: research support; Globus Medical: research support; Medtronic: other financial or material support, paid consultant, patents; Medtronic Sofamor Danek: IP royalties, paid presenter or speaker, research support; Neurosurgery RRC: board or committee member; NuVasive: IP royalties, paid consultant, paid presenter or speaker, research support, stock or stock options, patents; Spinal Deformity, Spine: editorial or governing board; Zimmer: IP royalties, paid consultant; SI Bone: consultant. Justin S. Smith: AlloSource: paid consultant; Alphatec Spine: stock or stock options; Astura: paid consultant; Cerapedics: paid consultant; Cervical Spine Research Society: board or committee member; DePuy: research support; Journal of Neurosurgery: Spine, Neurosurgery, Operative Neurosurgery: editorial or governing board; NuVasive: IP royalties, paid consultant; Stryker: paid consultant; Zimmer: IP royalties, paid consultant. Frank Schwab: Globus Medical: paid consultant; Medicrea: royalties; Medtronic Sofamor Danek: IP royalties; International Spine Society Group (ISSG): executive committee member; Zimmer-Biomet: IP royalties, paid consultant. Virginie Lafage: DePuy, a Johnson & Johnson Company: paid presenter or speaker; Globus Medical: paid consultant; NuVasive: IP royalties; The Permanente Medical Group: paid presenter or speaker; Implanet: paid presenter or speaker.

  • 1

    Blondel B, Schwab F, Ungar B, . Impact of magnitude and percentage of global sagittal plane correction on health-related quality of life at 2-years follow-up. Neurosurgery. 2012;71(2):341348.

    • Search Google Scholar
    • Export Citation
  • 2

    Glassman SD, Berven S, Bridwell K, . Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976). 2005;30(6):682688.

    • Search Google Scholar
    • Export Citation
  • 3

    Klineberg E, Schwab F, Smith JS, . Sagittal spinal pelvic alignment. Neurosurg Clin N Am. 2013;24(2):157162.

  • 4

    Smith JS, Shaffrey CI, Berven S, . Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up. Spine (Phila Pa 1976). 2009;34(16):16931698.

    • Search Google Scholar
    • Export Citation
  • 5

    Passias PG, Soroceanu A, Smith J, . 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.

    • Search Google Scholar
    • Export Citation
  • 6

    Passias PG, Horn SR, Poorman GW, . Clinical and radiographic presentation and treatment of patients with cervical deformity secondary to thoracolumbar proximal junctional kyphosis are distinct despite achieving similar outcomes: analysis of 123 prospective CD cases. J Clin Neurosci. 2018;56:121126.

    • Search Google Scholar
    • Export Citation
  • 7

    Passias PG, Jalai CM, Worley N, . Development of new-onset cervical deformity in nonoperative adult spinal deformity patients with 2-year follow-up. Int J Spine Surg. 2018;12(6):725734.

    • Search Google Scholar
    • Export Citation
  • 8

    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
  • 9

    Passias PG, Horn SR, Jalai CM, . Cervical alignment changes in patients developing proximal junctional kyphosis following surgical correction of adult spinal deformity. Neurosurgery. 2018;83(4):675682.

    • Search Google Scholar
    • Export Citation
  • 10

    Toyone T, Ozawa T, Kamikawa K, . Subsequent vertebral fractures following spinal fusion surgery for degenerative lumbar disease: a mean ten-year follow-up. Spine (Phila Pa 1976). 2010;35(21):19151918.

    • Search Google Scholar
    • Export Citation
  • 11

    Day LM, Ramchandran S, Jalai CM, . Thoracolumbar realignment surgery results in simultaneous reciprocal changes in lower extremities and cervical spine. Spine (Phila Pa 1976). 2017;42(11):799807.

    • Search Google Scholar
    • Export Citation
  • 12

    Oh T, Scheer JK, Eastlack R, . Cervical compensatory alignment changes following correction of adult thoracic deformity: a multicenter experience in 57 patients with a 2-year follow-up. J Neurosurg Spine. 2015;22(6):658665.

    • Search Google Scholar
    • Export Citation
  • 13

    Passias PG, Soroceanu A, Scheer J, . Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up. Spine J. 2015;15(8):17561763.

    • Search Google Scholar
    • Export Citation
  • 14

    Smith JS, Shaffrey CI, Lafage V, . Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy. J Neurosurg Spine. 2012;17(4):300307.

    • Search Google Scholar
    • Export Citation
  • 15

    Protopsaltis T, Bronsard N, Soroceanu A, . Cervical sagittal deformity develops after PJK in adult thoracolumbar deformity correction: radiographic analysis utilizing a novel global sagittal angular parameter, the CTPA. Eur Spine J. 2017;26(4):11111120.

    • Search Google Scholar
    • Export Citation
  • 16

    Segreto FA, Passias PG, Lafage R, . 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
  • 17

    Champain S, Benchikh K, Nogier A, . Validation of new clinical quantitative analysis software applicable in spine orthopaedic studies. Eur Spine J. 2006;15(6):982991.

    • Search Google Scholar
    • Export Citation
  • 18

    O’Brien MF, Kuklo TRTR, Blanke KM, . Spinal Deformity Study Group Radiographic Measurement Manual. Medtronic Sofamor Danek; 2005.

  • 19

    Rillardon L, Levassor N, Guigui P, . Validation of a tool to measure pelvic and spinal parameters of sagittal balance. Article in French. Rev Chir Orthop Reparatrice Appar Mot. 2003;89(3):218227.

    • Search Google Scholar
    • Export Citation
  • 20

    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
  • 21

    Ames CP, Blondel B, Scheer JK, . Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976). 2013;38(22 suppl 1):S149S160.

    • Search Google Scholar
    • Export Citation
  • 22

    Swinkels RAHM, Swinkels-Meewisse IEJCM. Normal values for cervical range of motion. Spine (Phila Pa 1976). 2014;39(5):362367.

  • 23

    Blondel B, Schwab F, Bess S, . Posterior global malalignment after osteotomy for sagittal plane deformity: it happens and here is why. Spine (Phila Pa 1976). 2013;38(7):E394E401.

    • Search Google Scholar
    • Export Citation
  • 24

    Tang JA, Scheer JK, Smith JS, . The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery. 2012;71(3):662669.

    • Search Google Scholar
    • Export Citation
  • 25

    Ha Y, Schwab F, Lafage V, . Reciprocal changes in cervical spine alignment after corrective thoracolumbar deformity surgery. Eur Spine J. 2014;23(3):552559.

    • Search Google Scholar
    • Export Citation
  • 26

    Bess S, Harris JE, Turner AWL, . The effect of posterior polyester tethers on the biomechanics of proximal junctional kyphosis: a finite element analysis. J Neurosurg Spine. 2017;26(1):125133.

    • Search Google Scholar
    • Export Citation
  • 27

    Jalai CM, Cruz DL, Diebo BG, . Full-body analysis of age-adjusted alignment in adult spinal deformity patients and lower-limb compensation. Spine (Phila Pa 1976). 2017;42(9):653661.

    • Search Google Scholar
    • Export Citation
  • 28

    Smith JS, Shaffrey CI, Bess S, . Recent and emerging advances in spinal deformity. Neurosurgery. 2017;80(3S):S70S85.

  • 29

    Roussouly P, Berthonnaud E, Dimnet J. Geometrical and mechanical analysis of lumbar lordosis in an asymptomatic population: proposed classification. Article in French. Rev Chir Orthop Reparatrice Appar Mot. 2003;89(7):632639.

    • Search Google Scholar
    • Export Citation
  • 30

    Jalai CM, Diebo BG, Cruz DL, . The impact of obesity on compensatory mechanisms in response to progressive sagittal malalignment. Spine J. 2017;17(5):681688.

    • Search Google Scholar
    • Export Citation

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