Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection

Breton G. Line, Shay Bess, Renaud Lafage, Virgine Lafage, Frank Schwab, Christopher Ames, Han Jo Kim, Michael Kelly, Munish Gupta, Douglas Burton, Robert Hart, Eric Otto Klineberg, Khaled Kebaish, Richard Hostin, Robert Eastlack, Christopher Shaffrey, Justin S. Smith

Research output: Contribution to journalArticle

Abstract

Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. Objective. Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data. PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) vs. within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n=235; 10.6%) vs. NONE (n=390: 20.3%; p<0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n=115) had the lowest rate of PJF (7.0%) vs. NONE (20.3%; p<0.05). ALIGN (n=246) had lower incidence of PJF than OVER (n=379; 12.0% vs. 19.2%, respectively; p<0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n=81; 9.9%), while OVER-NONE had the highest rate of PJF (n=225; 24.2%; p<0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.Level of Evidence: 3.

Original languageEnglish (US)
JournalSpine
DOIs
StateAccepted/In press - Jan 1 2019

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Propensity Score
Incidence
Databases
Kyphosis
Confounding Factors (Epidemiology)
Spine

Keywords

  • adult spinal deformity
  • age-adjusted sagittal alignment
  • prophylaxis
  • proximal junctional failure
  • proximal junctional kyphosis

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Clinical Neurology

Cite this

Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection. / Line, Breton G.; Bess, Shay; Lafage, Renaud; Lafage, Virgine; Schwab, Frank; Ames, Christopher; Kim, Han Jo; Kelly, Michael; Gupta, Munish; Burton, Douglas; Hart, Robert; Klineberg, Eric Otto; Kebaish, Khaled; Hostin, Richard; Eastlack, Robert; Shaffrey, Christopher; Smith, Justin S.

In: Spine, 01.01.2019.

Research output: Contribution to journalArticle

Line, BG, Bess, S, Lafage, R, Lafage, V, Schwab, F, Ames, C, Kim, HJ, Kelly, M, Gupta, M, Burton, D, Hart, R, Klineberg, EO, Kebaish, K, Hostin, R, Eastlack, R, Shaffrey, C & Smith, JS 2019, 'Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection', Spine. https://doi.org/10.1097/BRS.0000000000003249
Line, Breton G. ; Bess, Shay ; Lafage, Renaud ; Lafage, Virgine ; Schwab, Frank ; Ames, Christopher ; Kim, Han Jo ; Kelly, Michael ; Gupta, Munish ; Burton, Douglas ; Hart, Robert ; Klineberg, Eric Otto ; Kebaish, Khaled ; Hostin, Richard ; Eastlack, Robert ; Shaffrey, Christopher ; Smith, Justin S. / Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection. In: Spine. 2019.
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title = "Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection",
abstract = "Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. Objective. Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data. PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) vs. within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n=235; 10.6{\%}) vs. NONE (n=390: 20.3{\%}; p<0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n=115) had the lowest rate of PJF (7.0{\%}) vs. NONE (20.3{\%}; p<0.05). ALIGN (n=246) had lower incidence of PJF than OVER (n=379; 12.0{\%} vs. 19.2{\%}, respectively; p<0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n=81; 9.9{\%}), while OVER-NONE had the highest rate of PJF (n=225; 24.2{\%}; p<0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.Level of Evidence: 3.",
keywords = "adult spinal deformity, age-adjusted sagittal alignment, prophylaxis, proximal junctional failure, proximal junctional kyphosis",
author = "Line, {Breton G.} and Shay Bess and Renaud Lafage and Virgine Lafage and Frank Schwab and Christopher Ames and Kim, {Han Jo} and Michael Kelly and Munish Gupta and Douglas Burton and Robert Hart and Klineberg, {Eric Otto} and Khaled Kebaish and Richard Hostin and Robert Eastlack and Christopher Shaffrey and Smith, {Justin S.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1097/BRS.0000000000003249",
language = "English (US)",
journal = "Spine",
issn = "0362-2436",
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TY - JOUR

T1 - Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection

AU - Line, Breton G.

AU - Bess, Shay

AU - Lafage, Renaud

AU - Lafage, Virgine

AU - Schwab, Frank

AU - Ames, Christopher

AU - Kim, Han Jo

AU - Kelly, Michael

AU - Gupta, Munish

AU - Burton, Douglas

AU - Hart, Robert

AU - Klineberg, Eric Otto

AU - Kebaish, Khaled

AU - Hostin, Richard

AU - Eastlack, Robert

AU - Shaffrey, Christopher

AU - Smith, Justin S.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. Objective. Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data. PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) vs. within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n=235; 10.6%) vs. NONE (n=390: 20.3%; p<0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n=115) had the lowest rate of PJF (7.0%) vs. NONE (20.3%; p<0.05). ALIGN (n=246) had lower incidence of PJF than OVER (n=379; 12.0% vs. 19.2%, respectively; p<0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n=81; 9.9%), while OVER-NONE had the highest rate of PJF (n=225; 24.2%; p<0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.Level of Evidence: 3.

AB - Study Design. Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. Objective. Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. Summary of Background Data. PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF. Methods. Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) vs. within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. Results. 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n=235; 10.6%) vs. NONE (n=390: 20.3%; p<0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n=115) had the lowest rate of PJF (7.0%) vs. NONE (20.3%; p<0.05). ALIGN (n=246) had lower incidence of PJF than OVER (n=379; 12.0% vs. 19.2%, respectively; p<0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n=81; 9.9%), while OVER-NONE had the highest rate of PJF (n=225; 24.2%; p<0.05). Conclusion. Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.Level of Evidence: 3.

KW - adult spinal deformity

KW - age-adjusted sagittal alignment

KW - prophylaxis

KW - proximal junctional failure

KW - proximal junctional kyphosis

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DO - 10.1097/BRS.0000000000003249

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