Low-Density Pedicle Screw Constructs Are Associated with Lower Incidence of Proximal Junctional Failure in Adult Spinal Deformity Surgery

Wesley M. Durand, Kevin J. Disilvestro, Han Jo Kim, David K. Hamilton, Renaud Lafage, Peter G. Passias, Themistocles S. Protopsaltis, Virginie Lafage, Justin S. Smith, Christopher I. Shaffrey, Munish C Gupta, Eric O. Klineberg, Frank J. Schwab, Jeffrey L. Gum, Gregory M. Mundis, Robert K. Eastlack, Khaled M. Kebaish, Alexandra Soroceanu, Richard A. Hostin, Douglas C. BurtonShay Bess, Christopher P. Ames, Robert A. Hart, Alan H. Daniels

Research output: Contribution to journalArticlepeer-review

Abstract

Study Design.Retrospective cohort study.Objective.Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF).Summary of Background Data.PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF.Methods.Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.).Results.In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1).Conclusion.Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

Original languageEnglish (US)
Pages (from-to)463-469
Number of pages7
JournalSpine
Volume47
Issue number6
DOIs
StatePublished - Mar 15 2022

Keywords

  • Adult spinal deformity
  • Pedicle screw density
  • Proximal junctional failure

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Clinical Neurology

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