Abstract
Purpose
(a) Describe the time course of each mechanical complication, and (b) compare radiographic measurements and preoperative patient-reported outcome measures (PROMs) among each mechanical complication type.
Methods
A single-institution case–control study was undertaken of patients undergoing adult spinal deformity (ASD) surgery from 2009–2017. Exposure variables included patient demographics, operative variables, radiographic measurements, and preoperative PROMs, including Oswestry Disability Index (ODI), Numeric Rating Scale Back/Leg-pain scores (NRS-Back/Leg), and EuroQol-5D (EQ-5D). The primary outcomes were occurrence of a mechanical complication and time to complication. Due to overlapping occurrence, rod fracture and pseudarthrosis were grouped into one composite category.
Results
145 patients underwent ASD surgery and were followed for at least 2 years. 30/47 (63.8%) patients with proximal junctional kyphosis (PJK) required reoperation, whereas 27/31 (87.1%) patients with pseudarthrosis/rod fracture required reoperation (63.8% vs. 87.1%, Χ2 = −0.23, 95% CI −0.41, −0.05, p = 0.023). Cox regression showed no significant difference in time to reoperation between PJK and rod fracture/pseudarthrosis (HR = 0.97, 95% CI 0.85–1.11, p = 0.686). Distal junctional kyphosis (DJK) (N = 3; 2 reoperation) and implant failures (N = 4; 0 reoperations) were rare. Patients with PJK had significantly lower Hounsfield Units preoperatively compared to those with pseudarthrosis/rod fracture (138.2 ± 43.8 vs. 160.3 ± 41.0, mean difference (MD) = −22.1, 95% CI −41.8, −2.4, p = 0.028), more prior fusions (51.1% vs. 25.8%, Χ2 = 0.253, 95% CI 0.41, 0.46, p = 0.026), fewer instrumented vertebrae (9.2 ± 2.6 vs. 10.7 ± 2.5, MD = −1.5, 95% CI −2.7, −0.31, p = 0.013), and higher postoperative thoracic kyphosis (TK) (46.3 ± 12.7 vs. 34.9 ± 10.6, MD = 11.4, 95% CI 5.9, 16.9, p < 0.001). Higher postoperative C7 sagittal vertical axis (SVA) did not achieve a significant difference (80.7 ± 72.1 vs. 51.9 ± 57.3, MD = 28.8, 95% CI −1.9, 59.5, p = 0.066). No differences were seen in preoperative PROMs.
Conclusion
Patients with pseudarthrosis/rod fracture had a higher reoperation rate compared to those with PJK with similar time to reoperation. Moreover, patients with PJK had higher postoperative TK, lower Hounsfield Units, more prior fusions, and fewer instrumented levels compared to those with pseudarthrosis/rod fracture. The results of this single-institution study suggest that even though mechanical complications are often analyzed as a single group, important differences may exist between them.
Level of evidence
III.
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References
Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V (2019) Adult spinal deformity. Lancet 394:160–172. https://doi.org/10.1016/S0140-6736(19)31125-0
Youssef JA, Orndorff DO, Patty CA, Scott MA, Price HL, Hamlin LF, Williams TL, Uribe JS, Deviren V (2013) Current status of adult spinal deformity. Glob Spine J 3:51–62. https://doi.org/10.1055/s-0032-1326950
Ritter MA (2014) Commentary on “postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911)” Bolla M, van Poppel H, Tombal B, Vekemans K, Da Pozzo L, de Reijke TM, Verbaeys A, Bosset JF, van Velthoven R, Colombel M, van de Beek C, Verhagen P, van den Bergh A, Sternberg C, Gasser T, van Tienhoven G, Scalliet P, Haustermans K, Collette L; European Organisation for Research and Treatment of Cancer, Radiation Oncology and Genito-Urinary Groups. Department of Radiation Oncology, Centre Hospitalier Universitaire A Michallon, Grenoble, France.: Lancet 2012;380(9858):2018–27. doi: 10.1016/S0140-6736(12)61253-7. [Epub 2012 Oct 19]. Urol Oncol 32:372–373. https://doi.org/10.1016/j.urolonc.2013.09.023
Lafage V, Schwab F, Patel A, Hawkinson N, Farcy J-P (2009) Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine 34:E599–E606. https://doi.org/10.1097/BRS.0b013e3181aad219
Daubs MD, Lenke LG, Cheh G, Stobbs G, Bridwell KH (2007) Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine 32:2238–2244. https://doi.org/10.1097/BRS.0b013e31814cf24a
Soroceanu A, Burton DC, Oren JH, Smith JS, Hostin R, Shaffrey CI, Akbarnia BA, Ames CP, Errico TJ, Bess S, Gupta MC, Deviren V, Schwab FJ, Lafage V, International Spine Study Group (2016) Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine 41:1718–1723. https://doi.org/10.1097/BRS.0000000000001636
Scheer JK, Tang JA, Smith JS, Klineberg E, Hart RA, Mundis GM, Burton DC, Hostin R, O’Brien MF, Bess S, Kebaish KM, Deviren V, Lafage V, Schwab F, Shaffrey CI, Ames CP, International Spine Study Group (2013) Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database: clinical article. J Neurosurg Spine 19:464–470. https://doi.org/10.3171/2013.7.SPINE12901
Yadla S, Maltenfort MG, Ratliff JK, Harrop JS (2010) Adult scoliosis surgery outcomes: a systematic review. Neurosurg Focus 28:E3. https://doi.org/10.3171/2009.12.FOCUS09254
Sebaaly A, Gehrchen M, Silvestre C, Kharrat K, Bari TJ, Kreichati G, Rizkallah M, Roussouly P (2020) Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study. Eur Spine J 29:904–913. https://doi.org/10.1007/s00586-019-06253-1
Yagi M, Hosogane N, Fujita N, Okada E, Suzuki S, Tsuji O, Nagoshi N, Nakamura M, Matsumoto M, Watanabe K (2020) The patient demographics, radiographic index and surgical invasiveness for mechanical failure (PRISM) model established for adult spinal deformity surgery. Sci Rep 10:9341. https://doi.org/10.1038/s41598-020-66353-7
Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG (2011) Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Jt Surg Am 93:1057–1063. https://doi.org/10.2106/JBJS.J.00160
Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstück F, Pérez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A (2017) Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. JBJS 99:1661–1672. https://doi.org/10.2106/JBJS.16.01594
Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine 30:1643–1649. https://doi.org/10.1097/01.brs.0000169451.76359.49
Hart RA, McCarthy I, Ames CP, Shaffrey CI, Hamilton DK, Hostin R (2013) Proximal junctional kyphosis and proximal junctional failure. Neurosurg Clin N Am 24:213–218. https://doi.org/10.1016/j.nec.2013.01.001
Barton C, Noshchenko A, Patel V, Cain C, Kleck C, Burger E (2015) Risk factors for rod fracture after posterior correction of adult spinal deformity with osteotomy: a retrospective case-series. Scoliosis 10:30. https://doi.org/10.1186/s13013-015-0056-5
Merrill RK, Kim JS, Leven DM, Kim JH, Cho SK (2017) Multi-rod constructs can prevent rod breakage and pseudarthrosis at the lumbosacral junction in adult spinal deformity. Glob Spine J 7:514–520. https://doi.org/10.1177/2192568217699392
Jung J, Hyun S-J, Kim K-J, Jahng T-A (2019) Rod fracture after multiple-rod constructs for adult spinal deformity. J Neurosurg Spine 32:407–414. https://doi.org/10.3171/2019.9.SPINE19913
Bourghli A, Boissière L, Kieser D, Larrieu D, Pizones J, Alanay A, Pellise F, Kleinstück F, Obeid I, European Spine Study Group (2021) Multiple-rod constructs do not reduce pseudarthrosis and rod fracture after pedicle subtraction osteotomy for adult spinal deformity correction but improve quality of life. Neurospine 18:816–823. https://doi.org/10.14245/ns.2142596.298
Dinizo M, Srisanguan K, Dolgalev I, Errico TJ, Raman T (2021) Pseudarthrosis and rod fracture rates after transforaminal lumbar interbody fusion at the caudal levels of long constructs for adult spinal deformity surgery. World Neurosurg 155:e605–e611. https://doi.org/10.1016/j.wneu.2021.08.099
How NE, Street JT, Dvorak MF, Fisher CG, Kwon BK, Paquette S, Smith JS, Shaffrey CI, Ailon T (2019) Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors. Neurosurg Rev 42:319–336. https://doi.org/10.1007/s10143-018-0951-3
Jung J-M, Hyun S-J, Kim K-J, Jahng T-A (2019) Rod fracture after multiple-rod constructs for adult spinal deformity. J Neurosurg Spine. https://doi.org/10.3171/2019.9.SPINE19913
Yamato Y, Hasegawa T, Kobayashi S, Yasuda T, Togawa D, Yoshida G, Banno T, Oe S, Mihara Y, Matsuyama Y (2018) Treatment strategy for rod fractures following corrective fusion surgery in adult spinal deformity depends on symptoms and local alignment change. J Neurosurg Spine 29:59–67. https://doi.org/10.3171/2017.9.SPINE17525
Ha Y, Maruo K, Racine L, Schairer WW, Hu SS, Deviren V, Burch S, Tay B, Chou D, Mummaneni PV, Ames CP, Berven SH (2013) Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae: clinical article. J Neurosurg Spine 19:360–369. https://doi.org/10.3171/2013.5.SPINE12737
Lau D, Clark AJ, Scheer JK, Daubs MD, Coe JD, Paonessa KJ, LaGrone MO, Kasten MD, Amaral RA, Trobisch PD, Lee J-H, Fabris-Monterumici D, Anand N, Cree AK, Hart RA, Hey LA, Ames CP, Adult Spinal Deformity Committee SRS (2014) Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine 39:2093–2102. https://doi.org/10.1097/BRS.0000000000000627
Leven D, Cho SK (2016) Pseudarthrosis of the cervical spine: risk factors, diagnosis and management. Asian Spine J 10:776–786. https://doi.org/10.4184/asj.2016.10.4.776
Kim YJ, Bridwell KH, Lenke LG, Rinella AS, Edwards C, Edward C (2005) Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis. Spine 30:468–474. https://doi.org/10.1097/01.brs.0000153392.74639.ea
Lee KY, Lee J-H, Kang K-C, Im S-K, Lim HS, Choi SW (2021) Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion. J Neurosurg Spine. https://doi.org/10.3171/2020.8.SPINE201037
Guler UO, Cetin E, Yaman O, Pellise F, Casademut AV, Sabat MD, Alanay A, Grueso FSP, Acaroglu E, European Spine Study Group (2015) Sacropelvic fixation in adult spinal deformity (ASD); a very high rate of mechanical failure. Eur Spine J 24:1085–1091. https://doi.org/10.1007/s00586-014-3615-1
Pateder DB, Park Y-S, Kebaish KM, Cascio BM, Buchowski JM, Song EW, Shapiro MB, Kostuik JP (2006) Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis. Spine 31:E314–E319. https://doi.org/10.1097/01.brs.0000217619.57333.96
Cho W, Mason JR, Smith JS, Shimer AL, Wilson AS, Shaffrey CI, Shen FH, Novicoff WM, Fu K-MG, Heller JE, Arlet V (2013) Failure of lumbopelvic fixation after long construct fusions in patients with adult spinal deformity: clinical and radiographic risk factors: clinical article. J Neurosurg Spine 19:445–453. https://doi.org/10.3171/2013.6.SPINE121129
Denis F, Sun EC, Winter RB (2009) Incidence and risk factors for proximal and distal junctional kyphosis following surgical treatment for Scheuermann kyphosis: minimum five-year follow-up. Spine 34:E729–E734. https://doi.org/10.1097/BRS.0b013e3181ae2ab2
Lee C-S, Park J-S, Nam Y, Choi Y-T, Park S-J (2020) Long-term benefits of appropriately corrected sagittal alignment in reconstructive surgery for adult spinal deformity: evaluation of clinical outcomes and mechanical failures. J Neurosurg Spine. https://doi.org/10.3171/2020.7.SPINE201108
Kim DK, Kim JY, Kim DY, Rhim SC, Yoon SH (2017) Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data. J Korean Neurosurg Soc 60:174–180. https://doi.org/10.3340/jkns.2016.0707.014
Jacobs E, van Royen BJ, van Kuijk SMJ, Merk JMR, Stadhouder A, van Rhijn LW, Willems PC (2019) Prediction of mechanical complications in adult spinal deformity surgery-the GAP score versus the Schwab classification. Spine J 19:781–788. https://doi.org/10.1016/j.spinee.2018.11.013
Baum GR, Ha AS, Cerpa M, Zuckerman SL, Lin JD, Menger RP, Osorio JA, Morr S, Leung E, Lehman RA, Sardar Z, Lenke LG (2020) Does the global alignment and proportion score overestimate mechanical complications after adult spinal deformity correction? J Neurosurg Spine 34:96–102. https://doi.org/10.3171/2020.6.SPINE20538
Bari TJ, Ohrt-Nissen S, Hansen LV, Dahl B, Gehrchen M (2019) Ability of the global alignment and proportion score to predict mechanical failure following adult spinal deformity surgery-validation in 149 patients with two-year follow-up. Spine Deform 7:331–337. https://doi.org/10.1016/j.jspd.2018.08.002
Pizones J, Moreno-Manzanaro L, Sánchez Pérez-Grueso FJ, Vila-Casademunt A, Yilgor C, Obeid I, Alanay A, Kleinstück F, Acaroglu ER, Pellisé F, ESSG European Spine Study Group (2020) Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications. Eur Spine J 29:54–62. https://doi.org/10.1007/s00586-019-06176-x
Lee J, Park Y-S (2016) Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment. Asian Spine J 10:593–600. https://doi.org/10.4184/asj.2016.10.3.593
Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G (2008) Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine 33:2179–2184. https://doi.org/10.1097/BRS.0b013e31817c0428
Im S-K, Lee J-H, Kang K-C, Shin SJ, Lee KY, Park JJ, Kim MH (2020) Proximal junctional kyphosis in degenerative sagittal deformity after under- and overcorrection of lumbar lordosis: does overcorrection of lumbar lordosis instigate PJK? Spine 45:E933–E942. https://doi.org/10.1097/BRS.0000000000003468
Pocock SJ, Stone GW (2016) The primary outcome is positive—is that good enough? N Engl J Med 375:971–979. https://doi.org/10.1056/NEJMra1601511
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HC, SGR: data curation, drafting the paper. MEL, AMS: design and execution of the formal analysis. JH: designed research, conceptualization, interpretation of the analysis. AMA, BFS: conducted review and editing. SLZ: designed research, data acquisition, conceptualization, interpretation of the analysis. Final approval of the version to be published. All authors are contributed effort to the study.
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Chanbour, H., Roth, S.G., LaBarge, M.E. et al. The postoperative course of mechanical complications in adult spinal deformity surgery. Spine Deform 11, 175–185 (2023). https://doi.org/10.1007/s43390-022-00576-8
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DOI: https://doi.org/10.1007/s43390-022-00576-8