TY - JOUR
T1 - The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset
T2 - Mean 4.5-Year Follow-up
AU - Gomez, Jaime A.
AU - Kubat, Ozren
AU - Tovar Castro, Mayra A.
AU - Hanstein, Regina
AU - Flynn, Tara
AU - Lafage, Virginie
AU - Hurry, Jennifer K.
AU - Soroceanu, Alexandra
AU - Schwab, Frank
AU - Skaggs, David L.
AU - El-Hawary, Ron
N1 - Funding Information:
V.L. reports grants from Depuy Synthese Spine, grants from SRS, grants from NIH, grants from DePuy Spine, personal fees from NuVasive, personal fees from Medicrea, personal fees from DePuy Spine, personal fees from Nemaris Inc., other from Nemaris Inc., outside the submitted work. J.A.G. reports an Educational grant from K2M Inc., outside the submitted work. J.F. reports direct stock ownership in Nemaris Inc.; support of non–study-related clinical or research effort from DePuy Spine, NuVasive, Stryker, and K2M; and being a consultant for and receiving speaking/teaching arrangements from Zimmer-Biomet, Medicrea, MSD, K2M, and NuVasive. D.S. reports grants from Pediatric Orthopaedic Society of North America & Scoliosis Research Society, paid to Columbia University, and Ellipse (Co-PI, paid to G.S.F.); personal fees from ZimmerBiomet, Medtronic, Zipline Medical Inc., Orthobullets, Grand Rounds (a healthcare navigation company), and Greensunmedical; other from Zipline Medical Inc., Green Sun Medical, and Orthobullets; nonfinancial support from Growing Spine Study Group, Scoliosis Research Society, and Growing Spine Foundation; personal fees from ZimmerBiomet, Medtronic, Johnson & Johnson, and Medtronic & ZimmerBiomet; other from Wolters Kluwer Health—Lippincott Williams & Wilkins, Biomet Spine, and Orthobullets, Co-Editor in Chief, outside the submitted work. R.E.-H. reports personal fees from DePuy Synthes Spine and Medtronic Spine; grants from DePuy Synthes Spine and Medtronic Spine; personal fees from Apifix Ltd; other from Children’s Spine Foundation and Pediatric Orthopedic Society of North America, outside the submitted work. The remaining authors declare no conflicts of interest.
Funding Information:
Supported by the Scoliosis Research Society (SRS) to R.E.-H.
Publisher Copyright:
© Journal of Pediatric Orthopaedics. All rights reserved.
PY - 2020/7/1
Y1 - 2020/7/1
N2 - Background:Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS).Methods:A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed.Results:At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038).Conclusions:In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs.Level of Evidence:Level III.
AB - Background:Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS).Methods:A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed.Results:At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038).Conclusions:In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs.Level of Evidence:Level III.
KW - EOS
KW - PJK
KW - distraction
KW - distraction-based growth friendly implants
KW - early-onset scoliosis
KW - growth-friendly surgery
KW - pelvic tilt
KW - proximal junctional kyphosis
KW - spine
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U2 - 10.1097/BPO.0000000000001516
DO - 10.1097/BPO.0000000000001516
M3 - Article
C2 - 32501899
AN - SCOPUS:85086007900
VL - 40
SP - 261
EP - 266
JO - Journal of Pediatric Orthopaedics
JF - Journal of Pediatric Orthopaedics
SN - 0271-6798
IS - 6
ER -