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Comparative Study
. 2018 Jan;52(1):7-11.
doi: 10.1016/j.aott.2017.11.012. Epub 2017 Dec 28.

Selection of distal fusion level in terms of distal junctional kyphosis in Scheuermann kyphosis. A comparison of 3 methods

Fatih Dikici  1 , Turgut Akgul  2 , Kerim Sariyilmaz  3 , Murat Korkmaz  4 , Okan Ozkunt  1 , Cuneyt Sar  2 , Unsal Domanic  1
Affiliations
Comparative Study

Selection of distal fusion level in terms of distal junctional kyphosis in Scheuermann kyphosis. A comparison of 3 methods

Fatih Dikici et al. Acta Orthop Traumatol Turc. 2018 Jan.

Abstract

Objective: The aim of this study was to investigate the effect of distal fusion level selection on the distal junctional kyphosis (DJK) in Scheuermann kyphosis (SK) patients who underwent posterior fusion.

Methods: Thirty-nine SK patients who underwent posterior fusion with a minimum follow-up of 3 years were retrospectively evaluated. According to the distal fusion level, patients were divided into 3 groups. Group S; lowest instrumented vertebra (LIV) was the sagittal stable vertebra (SSV), Group F; LIV was the first lordotic vertebra (FLV) and, Group L; LIV was the lower end vertebra (LEV). DJK was evaluated according to distal level selection.

Results: Thoracic kyphosis (TK) decreased from 73.3° (SD ± 7.9°) to 39° (SD ± 8.7°) postoperatively, with a mean correction rate of 46% (SD ± 13) (p < 0.0001). In 11 patients, FLV and SSV was the same vertebra. In remaining 28 patients, 10 patients were in Group S, 15 patients were in Group F and 3 patients were in Group L. In Group S, none of them developed DJK, however, DJK was observed 9 of 15 patients in Group F. DJK was developed in all cases in Group L. There is a statistically higher risk for developing DJK when FLV or LEV was selected as LIV (p < 0.05).

Conclusion: Selecting SSV for the distal fusion level has been found to be effective for preventing DJK. Selecting distal fusion level proximal to SSV will increase the risk of DJK which may become symptomatic and require revision surgery.

Level of evidence: Level IV, therapeutic study.

Keywords: Distal junctional kyphosis; First lordotic vertebra; Lower end vertebra; Sagittal stable vertebra; Scheuermann kyphosis.

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Figures

Fig. 1
Fig. 1
The determination of the sagittal stable vertebra (SSV), first lordotic vertebra (FLV) and lower end vertebra (LEV). SSV (red dotted line) is the most proximal vertebra touched by the posterior sacral vertical line. FLV (green line) is the distal first vertebra of the kyphosis where the disc space turned to lordosis. LEV (yellow dotted line) is determined according to Cobb method. In this patient SSV and FLV is the same vertebra, which is L1 and, LEV is T12.
Fig. 2
Fig. 2
The distribution of patients to groups.
Fig. 3
Fig. 3
DJK distribution of patients.
Fig. 4
Fig. 4
Twenty year-old women with SK. A – Preoperative lateral X-ray shows that FLV is L3 and SSV is L4. The patient was operated through a posterior approach through T2-L3. B – After 1 month DJK was observed. C – Six months later distal screw was broken (white circle). D – Because of being symptomatic, the instrumentation level extended to L4, which was the SSV preoperatively.
See this image and copyright information in PMC

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