Predictive model for distal junctional kyphosis after cervical deformity surgery

for the ISSG

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background Context: Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care. Purpose: The present study aimed to develop a risk index for DJK development in the first year after surgery. Study Design/Setting: This is a retrospective review of a prospective multicenter cervical deformity database. Patient Sample: Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2–7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2–C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°). Outcome Measures: Development of DJK at any time before 1 year. Methods: Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<−10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <−10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size. Results: Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11–0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99–16.14); (2) kyphosis<−50.6° (OR: 5.89, CI: 0.07–0.43); (3) C2–C7 lordosis<−12° (OR: 5.7, CI: 0.08–0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28–13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20–13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90–13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21–5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02–6.34) were the most important predictors of DJK. Conclusions: In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.

Original languageEnglish (US)
JournalSpine Journal
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Kyphosis
Lordosis
Chin
Incidence
Scoliosis
Osteotomy
Patient Selection
Patient Care
Outcome Assessment (Health Care)
Databases

Keywords

  • Cervical
  • Cervical alignment
  • Cervical deformity
  • Deformity
  • Distal junctional kyphosis
  • Outcomes
  • Sagittal malalignment
  • Surgery
  • Surgical correction

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Predictive model for distal junctional kyphosis after cervical deformity surgery. / for the ISSG.

In: Spine Journal, 01.01.2018.

Research output: Contribution to journalArticle

@article{08ca658d981e49e3a6528719e00a9cae,
title = "Predictive model for distal junctional kyphosis after cervical deformity surgery",
abstract = "Background Context: Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care. Purpose: The present study aimed to develop a risk index for DJK development in the first year after surgery. Study Design/Setting: This is a retrospective review of a prospective multicenter cervical deformity database. Patient Sample: Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2–7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2–C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°). Outcome Measures: Development of DJK at any time before 1 year. Methods: Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<−10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <−10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size. Results: Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3{\%} female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5{\%}, approach: 46.5{\%} posterior, 17.8{\%} anterior, 35.7{\%} combined). In 2 years after surgery, 6{\%} of patients were diagnosed with clinical DJK; however, 23.8{\%} of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11–0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99–16.14); (2) kyphosis<−50.6° (OR: 5.89, CI: 0.07–0.43); (3) C2–C7 lordosis<−12° (OR: 5.7, CI: 0.08–0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28–13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20–13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90–13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21–5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02–6.34) were the most important predictors of DJK. Conclusions: In a surgical cohort of patients with cervical deformity, we found a 23.8{\%} incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.",
keywords = "Cervical, Cervical alignment, Cervical deformity, Deformity, Distal junctional kyphosis, Outcomes, Sagittal malalignment, Surgery, Surgical correction",
author = "{for the ISSG} and Passias, {Peter G.} and Dennis Vasquez-Montes and Poorman, {Gregory W.} and Themistocles Protopsaltis and Horn, {Samantha R.} and Bortz, {Cole A.} and Frank Segreto and Bassel Diebo and Chris Ames and Justin Smith and Virginie LaFage and Renaud LaFage and Klineberg, {Eric Otto} and Chris Shaffrey and Shay Bess and Frank Schwab",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.spinee.2018.04.017",
language = "English (US)",
journal = "Spine Journal",
issn = "1529-9430",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Predictive model for distal junctional kyphosis after cervical deformity surgery

AU - for the ISSG

AU - Passias, Peter G.

AU - Vasquez-Montes, Dennis

AU - Poorman, Gregory W.

AU - Protopsaltis, Themistocles

AU - Horn, Samantha R.

AU - Bortz, Cole A.

AU - Segreto, Frank

AU - Diebo, Bassel

AU - Ames, Chris

AU - Smith, Justin

AU - LaFage, Virginie

AU - LaFage, Renaud

AU - Klineberg, Eric Otto

AU - Shaffrey, Chris

AU - Bess, Shay

AU - Schwab, Frank

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background Context: Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care. Purpose: The present study aimed to develop a risk index for DJK development in the first year after surgery. Study Design/Setting: This is a retrospective review of a prospective multicenter cervical deformity database. Patient Sample: Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2–7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2–C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°). Outcome Measures: Development of DJK at any time before 1 year. Methods: Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<−10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <−10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size. Results: Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11–0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99–16.14); (2) kyphosis<−50.6° (OR: 5.89, CI: 0.07–0.43); (3) C2–C7 lordosis<−12° (OR: 5.7, CI: 0.08–0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28–13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20–13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90–13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21–5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02–6.34) were the most important predictors of DJK. Conclusions: In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.

AB - Background Context: Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care. Purpose: The present study aimed to develop a risk index for DJK development in the first year after surgery. Study Design/Setting: This is a retrospective review of a prospective multicenter cervical deformity database. Patient Sample: Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2–7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2–C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°). Outcome Measures: Development of DJK at any time before 1 year. Methods: Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<−10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <−10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size. Results: Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11–0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99–16.14); (2) kyphosis<−50.6° (OR: 5.89, CI: 0.07–0.43); (3) C2–C7 lordosis<−12° (OR: 5.7, CI: 0.08–0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28–13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20–13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90–13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21–5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02–6.34) were the most important predictors of DJK. Conclusions: In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.

KW - Cervical

KW - Cervical alignment

KW - Cervical deformity

KW - Deformity

KW - Distal junctional kyphosis

KW - Outcomes

KW - Sagittal malalignment

KW - Surgery

KW - Surgical correction

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UR - http://www.scopus.com/inward/citedby.url?scp=85048590157&partnerID=8YFLogxK

U2 - 10.1016/j.spinee.2018.04.017

DO - 10.1016/j.spinee.2018.04.017

M3 - Article

C2 - 29709551

AN - SCOPUS:85048590157

JO - Spine Journal

JF - Spine Journal

SN - 1529-9430

ER -