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. 2022 Jan;12(1):102-109.
doi: 10.1177/2192568220947050. Epub 2020 Aug 30.

Sarcopenia Is an Independent Risk Factor for Proximal Junctional Disease Following Adult Spinal Deformity Surgery

Ananth Eleswarapu  1 , Daniel O'Connor  2 , Flynn Andrew Rowan  3 , Hai Van Le  2 , Joseph B Wick  2 , Yashar Javidan  2 , Roberto Rolando  2 , Eric O Klineberg  2
Affiliations

Sarcopenia Is an Independent Risk Factor for Proximal Junctional Disease Following Adult Spinal Deformity Surgery

Ananth Eleswarapu et al. Global Spine J. 2022 Jan.

Abstract

Study design: Retrospective cohort study.

Objectives: Sarcopenia is a risk factor for medical complications following spine surgery. However, the role of sarcopenia as a risk factor for proximal junctional disease (PJD) remains undefined. This study evaluates whether sarcopenia is an independent predictor of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery.

Methods: ASD patients who underwent thoracic spine to pelvis fusion with 2-year clinical and radiographic follow-up were reviewed for development of PJK and PJD. Average psoas cross-sectional area on preoperative axial computed tomography or magnetic resonance imaging at L4 was recorded. Previously described PJD risk factors were assessed for each patient, and multivariate linear regression was performed to identify independent risk factors for PJK and PJF. Disease-specific thresholds were calculated for sarcopenia based on psoas cross-sectional area.

Results: Of 32 patients, PJK and PJF occurred in 20 (62.5%) and 12 (37.5%), respectively. Multivariate analysis demonstrated psoas cross-sectional area to be the most powerful independent predictor of PJK (P = .02) and PJF (P = .009). Setting ASD disease-specific psoas cross-sectional area thresholds of <12 cm2 in men and <8 cm2 in women resulted in a PJF rate of 69.2% for patients below these thresholds, relative to 15.8% for those above the thresholds.

Conclusions: Sarcopenia is an independent, modifiable predictor of PJK and PJF, and is easily assessed on standard preoperative computed tomography or magnetic resonance imaging. Surgeons should include sarcopenia in preoperative risk assessment and consider added measures to avoid PJF in sarcopenic patients.

Keywords: adult spinal deformity; degenerative; proximal junctional failure; proximal junctional kyphosis; revision; sarcopenia.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Klineberg has worked as a consultant for DePuy Synthes Spine, Stryker, and Medicrea, and Drs Klineberg and Javidan have received honoraria and a fellowship grant for University of California, Davis from AOSpine. Dr Javidan has worked as a consultant for NuVasive, Alphatec, and Stryker, holds stocks in Alphatec, and has served as a consultant for Medicrea.

Figures

Figure 1.
Figure 1.
Radiograph of a patient who initially underwent T10-pelvis posterior spinal fusion for adult degenerative scoliosis (left panel). At 2-year follow-up (middle panel), the patient had developed proximal junctional failure at T9 with magnetic resonance imaging demonstrating severe stenosis (right panel) and neurologic deficits necessitating revision surgery.
Figure 2.
Figure 2.
Example images of patients with and without sarcopenia. Left panel shows axial T2 magnetic resonance imaging (MRI) at the level of L4 pedicles in a 63-year-old woman with psoas cross-sectional area of 682 mm2. She went on to develop hardware failure and proximal junctional disease (PJD), necessitating revision surgery. Right panel shows axial T2 MRI in a 69-year-old man with psoas cross-sectional area of 1996 mm2; he did not develop PJD at final follow-up.
Figure 3.
Figure 3.
Measurement of psoas cross-sectional area on axial magnetic resonance imaging using region of interest tool.
Figure 4.
Figure 4.
Intraoperative photo showing ligament augmentation with polyester fiber tape as a prophylaxis measure against proximal junctional kyphosis (PJK). The tape is passed through the spinous process of the upper instrumented vertebra and tensioned through a crosslink, tethering the junctional zone against flexion deformity forces.
See this image and copyright information in PMC

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