Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 May 14;17(1):271.
doi: 10.1186/s13018-022-03173-7.

Proximal junctional fractures after long-segment instrumented fusion: comparisons between upper instrumented vertebrae and upper instrumented vertebrae + 1

Jen-Chung Liao  1 , Wen-Jer Chen  2 , Shiny Chih-Hsuan Wu  2
Affiliations

Proximal junctional fractures after long-segment instrumented fusion: comparisons between upper instrumented vertebrae and upper instrumented vertebrae + 1

Jen-Chung Liao et al. J Orthop Surg Res. .

Abstract

Introduction: Proximal junctional failure (PJF) is a well-known complication after long-segment (at least 4 vertebral levels) instrumented fusion. The etiologies of PJF include degenerative processes or are fracture induced. The fracture type of PJF includes vertebral fractures developed at the upper instrumented vertebrae (UIV) or UIV + 1. The purpose of this study was to investigate clinical and radiographic features of these two subtypes of PJF and to analyze risk factors in these patients.

Method: In total, forty-two patients with PJF who underwent revision surgery were included. Twenty patients suffered fractures at the UIV, and the other 22 cases had fractures at UIV + 1. The weighted Charlson Comorbidity Index (CCI) and bone mineral density (BMD) T scores for these patients were recorded. Surgery-related data of index surgery and complications were collected. Radiographic parameters including pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), lumbar lordosis (LL), and PI-LL were recorded in both groups before and after the revision surgery.

Result: Both groups had severe osteoporosis and comorbidities. The interval between the index surgery and revision surgery was shorter in the UIV group than in the UIV + 1 group (8.2 months vs. 35.9 months; p < 0.001). The analysis for radiographic parameters in UIV and UIV + 1 group demonstrated no significant change before and after the revision surgery. However, the preoperative radiographic analysis showed a larger PT (31.5° vs. 23.2°, p = 0.013), PI (53.7° vs. 45.3°, p = 0.035), and SVA (78.6° vs. 59.4°, p = 0.024) in the UIV group compared to the UIV + 1 group. The postoperative radiographic analysis showed a larger PI-LL (27.8° vs. 18.1°, p = 0.016) in the UIV group compared to the UIV + 1 group.

Conclusion: PJF in the UIV group tends to occur earlier than in the UIV + 1 group. Moreover, more severe global sagittal imbalances were found in the UIV group than in UIV + 1 group.

PubMed Disclaimer

Conflict of interest statement

The author declares that there no conflicts of interest regarding the publication of this paper.

Figures

Fig. 1
Fig. 1
A case in the UIV group: A the patient who underwent L1-S1 instrumented fusion, B 6 weeks later, suffered from fracture at upper instrumented vertebrae (L1), C extended instrumentation to T10 was performed
Fig. 2
Fig. 2
A case in the UIV + 1 group: A the patient who underwent L2-S1 instrumented fusion, B fracture at upper instrumented vertebrae + 1 (L1) was developed 18 months later, C computed tomography showed L1 fracture, D L1 vertebroplasty was performed
Fig. 3
Fig. 3
This figure demonstrated radiographic parameters on a whole spine lateral radiograph. LL lumbar lordosis, PI pelvic incidence, PLK proximal local kyphosis, PT pelvic tilt, SS sacral slope, SVA sagittal vertical axis
Fig. 4
Fig. 4
Comparisons of preoperatively radiographic parameters between UIV and UIV + 1 groups. PT, PI, and SVA had significant differences
Fig. 5
Fig. 5
Comparisons of postoperatively radiographic parameters between study and control groups. Only PI-LL had a significant difference
See this image and copyright information in PMC

References

    1. Bridwell KH, Lenke LG, Cho SK, Pahys JM, Zebala LP, Dorward IG, Cho W, Baldus C, Hill BW, Kang MM. Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery. 2013;72:899–906. doi: 10.1227/NEU.0b013e31828bacd8. - DOI - PubMed
    1. Smith MW, Annis P, Lawrence BD, Daubs MD, Brodke DS. Acute proximal junctional failure in patients with preoperative sagittal imbalance. Spine J. 2015;15:2142–2148. doi: 10.1016/j.spinee.2015.05.028. - DOI - PubMed
    1. Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Koester L, Hensley M. Proximal junctional vertebral fracture in adults after spinal deformity surgery using pedicle screw constructs: analysis of morphological features. Spine. 2010;35:138–145. doi: 10.1097/BRS.0b013e3181c8f35d. - DOI - PubMed
    1. Hart RA, Prendergast MA, Roberts WG, Nesbit GM, Barnwell SL. Proximal junctional acute collapse cranial to multi-level lumbar fusion: a cost analysis of prophylactic vertebral augmentation. Spine J. 2008;8:875–881. doi: 10.1016/j.spinee.2008.01.015. - DOI - PubMed
    1. Theologis AA, Miller L, Callahan M, Lau D, Zygourakis C, Scheer JK, Burch S, Pekmezci M, Chou D, Tay B, Mummaneni P, Berven S, Deviren V, Ames CP. Economic impact of revision surgery for proximal junctional failure after adult spinal deformity surgery: a cost analysis of 57 operations in a 10-year experience at a major deformity center. Spine. 2016;41:E964–E972. doi: 10.1097/BRS.0000000000001523. - DOI - PubMed

MeSH terms