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      Risk Factors and Three Radiological Predictor Models for the Progression of Proximal Junctional Kyphosis in Adult Degenerative Scoliosis Following Posterior Corrective Surgery: 113 Cases With 2-years Minimum Follow-Up

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          Abstract

          Study design

          Retrospective cohort study.

          Objective

          To identify risk factors and predictive models for proximal junctional kyphosis (PJK) in a long-term follow-up of patients with adult degenerative scoliosis (ADS) following posterior corrective surgeries.

          Materials and Methods

          A consecutive 113 ADS patients undergoing posterior corrective surgery between January 2008 and April 2019 with minimum 2-year follow-up were included. All patients underwent preoperative, postoperative, and final follow-up by X-ray imaging. Multivariate logistic analysis was performed on various risk factors and radiological predictor models.

          Results

          PJK was identified radiographically in 46.9% of patients. Potential risk factors for PJK included postoperative thoracic kyphosis (TK) ( P < .05), final follow-up Pelvic Tilt (PT) ( P < .05), PT changes at final follow-up ( P < .05), age over 55 years old at the surgery ( P < .05), theoretical thoracic kyphosis–actual thoracic kyphosis mismatch (TK mismatch) ( P < .05) and theoretical lumbar lordosis–acutal lumbar lordosis mismatch (LL mismatch) ( P < .05). As for the predictive models, PJK was predictive by the following indicators: preoperative global sagittal alignment ≥45° (Model 1), postoperative pelvic incidence–lumbar lordosis mismatch (PI–LL)≤10° and postoperative PI–LL overcorrection (Model 2), and TK+LL≥0° (Model 3) ( P < .05). Postoperative TK mismatch (OR = 1.064) was independent as risk factors for PJK, with the cut-off values respectively set at −28.56° to predict occurrence of PJK.

          Conclusion

          The risk of radiographic PJK increases with an age over 55 years old and higher postoperative TK. In addition, postoperative TK mismatch is an independent risk factor for developing PJK. All three predictive models could effectively indicate the occurrence of PJK.

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          Most cited references34

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          Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.

          Raphaël Vialle, Nicolas Levassor, Ludovic Rillardon … (2005)
          There is an increasing recognition of the clinical importance of the sagittal plane alignment of the spine. A prospective study of several radiographic parameters of the sagittal profile of the spine was conducted to determine the physiological values of these parameters, to calculate the variations of these parameters according to epidemiological and morphological data, and to study the relationships among all of these parameters. Sagittal radiographs of the head, spine, and pelvis of 300 asymptomatic volunteers, made with the subject standing, were evaluated. The following parameters were measured: lumbar lordosis, thoracic kyphosis, T9 sagittal offset, sacral slope, pelvic incidence, pelvic tilt, intervertebral angulation, and vertebral wedging angle from T9 to S1. The radiographs were digitized, and all measurements were performed with use of a software program. Two different analyses, a descriptive analysis characterizing these parameters and a multivariate analysis, were performed in order to study the relationships among all of them. The mean values (and standard deviations) were 60 degrees 10 degrees for maximum lumbar lordosis, 41 degrees +/- 8.4 degrees for sacral slope, 13 degrees +/- 6 degrees for pelvic tilt, 55 degrees +/-10.6 degrees for pelvic incidence, and 10.3 degrees +/- 3.1 degrees for T9 sagittal offset. A strong correlation was found between the sacral slope and the pelvic incidence (r = 0.8); between maximum lumbar lordosis and sacral slope (r = 0.86); between pelvic incidence and pelvic tilt (r = 0.66); between maximum lumbar lordosis and pelvic incidence, pelvic tilt, and maximum thoracic kyphosis (r = 0.9); and, finally, between pelvic incidence and T9 sagittal offset, sacral slope, pelvic tilt, maximum lumbar lordosis, and thoracic kyphosis (r = 0.98). The T9 sagittal offset, reflecting the sagittal balance of the spine, was dependent on three separate factors: a linear combination of the pelvic incidence, maximum lumbar lordosis, and sacral slope; the pelvic tilt; and the thoracic kyphosis. This description of the physiological spinal sagittal balance should serve as a baseline in the evaluation of pathological conditions associated with abnormal angular parameter values. Before a patient with spinal sagittal imbalance is treated, the reciprocal balance between various spinal angular parameters needs to be taken into account. The correlations between angular parameters may also be useful in calculating the corrections to be obtained during treatment.
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            Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity.

            Virginie Lafage, Frank Schwab, Ashish Patel … (2009)
            Prospective radiographic and clinical analysis. Investigate the relationship between spino-pelvic parameters and patient self reported outcomes on adult subjects with spinal deformities. It is becoming increasingly recognized that the study of spinal alignment should include pelvic position. While pelvic incidence determines lumbar lordosis, pelvic tilt (PT) is a positional parameter reflecting compensation to spinal deformity. Correlation between plumbline offset (sagittal vertical axis [SVA]) and Health Related Quality of Life (HRQOL) measures has been demonstrated, but such a study is lacking for PT. This prospective study was carried out on 125 adult patients suffering from spinal deformity (mean age: 57 years). Full-length free-standing radiographs including the spine and pelvis were available for all patients. HRQOL instruments included: Oswestry Disability Index, Short Form-12, Scoliosis Research Society. Correlation analysis between radiographic spinopelvic parameters and HRQOL measures was pursued. Correlation analysis revealed no significance pertaining to coronal plane parameters. Significant sagittal plane correlations were identified. SVA and truncal inclination measured by T1 spinopelvic inclination (T1-SPI) (angle between T1-hip axis and vertical) correlated with: Scoliosis Research Society (appearance, activity, total score), Oswestry Disability Index, and Short Form-12 (physical component score). Correlation coefficients ranged from 0.42 < r < 0.55 (P < 0.0001). T1-SPI revealed greater correlation with HRQOL compared to SVA. PT showed correlation with HRQOL (0.28 < r < 0.42) and with SVA (r = 0.64, P < 0.0001). This study confirms that pelvic position measured via PT correlates with HRQOL in the setting of adult deformity. High values of PT express compensatory pelvic retroversion for sagittal spinal malalignment. This study also demonstrates significant T1-SPI correlation with HRQOL measures and outperforms SVA. This parameter carries the advantage of being an angular measurement which avoids the error inherent in measuring offsets in noncalibrated radiographs.
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              Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis.

              Lawrence Lenke, Anthony Rinella, Ira Kim … (2005)
              To analyze patient outcomes and risk factors associated with proximal junctional kyphosis (PJK) in adults undergoing long posterior spinal fusion. To determine the incidence of PJK and its effect on patient outcomes and to identify any risk factors associated with developing PJK. The incidence of PJK and its affect on outcomes in adult deformity patients is unknown. No study has concentrated on outcomes of patients with PJK. Risk factors for developing PJK are unknown. Radiographic data on 81 consecutive adult deformity patients with minimum 2-year follow-up (average 5.3 years, range 2-16 years) treated with long instrumented segmental posterior spinal fusion was collected. Preoperative diagnosis was adult scoliosis, sagittal imbalance or both. Radiographic measurements analyzed included the sagittal Cobb angle at the proximal junction on preoperative, early postoperative, and final follow-up standing long cassette radiographs. Additional measurements used for analysis included the C7-Sacrum sagittal plumb and the T5-T12 sagittal Cobb. Postoperative SRS-24 scores were available on 73 patients. Incidence of PJK as defined was 26%. Patients with PJK did not have lower outcomes scores. PJK did not produce a more positive sagittal C7 plumb. PJK was more common at T3 in the upper thoracic spine. Incidence of proximal junctional kyphosis was high, but SRS-24 scores were not significantly affected in patients with PJK. The sagittal C7 plumb was not significantly more positive in PJK patients. No patient, radiographic, or instrumentation variables were identified as risk factors for developing PJK.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Global Spine J
                Journal ID (iso-abbrev): Global Spine J
                Journal ID (hwp): spgsj
                Journal ID (publisher-id): GSJ
                Title: Global Spine Journal
                Publisher: SAGE Publications (Sage CA: Los Angeles, CA )
                ISSN (Print): 2192-5682
                ISSN (Electronic): 2192-5690
                Publication date (Electronic): 5 March 2022
                Publication date (Print): October 2023
                Volume: 13
                Issue: 8
                Pages: 2285-2295
                Affiliations
                [1 ]Orthopedic Department, Ringgold 66482, universityPeking University Third Hospital; , Beijing, China
                [2 ]Ringgold 66482, universityEngineering Research Center of Bone and Joint Precision Medicine; , Beijing, China
                [3 ]Ringgold 66482, universityBeijing Key Laboratory of Spinal Disease Research; , Beijing, China
                [4 ]School of Public Health, Ringgold 66482, universityPeking University health Science Centre; , Beijing, China
                [5 ]Operating Room, Ringgold 33133, universityPeking University Third Hospital; , Beijing, China
                Author notes
                [*]Miao Yu, Department of Orthopaedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China. Email: miltonyu@ 123456126.com

                *Junyu Li and Han Xiao equally contributed to this article.

                Author information
                https://orcid.org/0000-0002-6108-2789
                https://orcid.org/0000-0002-6595-1910
                https://orcid.org/0000-0002-5663-5238
                https://orcid.org/0000-0001-8140-0361
                https://orcid.org/0000-0001-9512-5436
                https://orcid.org/0000-0002-0788-6372
                Article
                Publisher ID: 10.1177_21925682221079791
                DOI: 10.1177/21925682221079791
                PMC ID: 10538339
                PubMed ID: 35249410
                SO-VID: 36e6e82e-4a74-4ea0-afc2-f4491b896ea4
                Copyright © © The Author(s) 2022
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                Subject: Original Articles
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                Keywords: radiology,sagittal alignment,tk mismatch,predictive model,proximal junctional kyphosis,adult degenerative scoliosis
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                Keywords: radiology, sagittal alignment, tk mismatch, predictive model, proximal junctional kyphosis, adult degenerative scoliosis

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