Fig. 18.1
PJK/PJF prophylaxis using rib fixation. (a, b) Preoperative AP and lateral radiographs demonstrating iatrogenic flat back deformity with global sagittal imbalance. Preoperative PI–LL mismatch measured 25° (PI = 50°, LL = 25°). (c, d) Postoperative AP and lateral views status post T10-pelvis fusion with L3 PSO and quadruple rod construct, illustrating the senior author’s technique of using sublaminar hooks (DePuy Synthes Expedium 5.5 mm sublaminar hooks, J&J Inc.) encircled around the UIV +1 rib and connected to the midline rods via bilateral titanium rods and connectors. Her PI–LL mismatch became normalized postoperatively (PI = 50° and LL = 58°). (e) Intraoperative photograph illustrating the rib fixation construct
Ligament Augmentation
As disruption of the posterior ligamentous complex is thought to play an important role in the pathogenesis of PJK and PJF, technical measures aimed at reinforcing the posterior tension band may prove to be effective. The main objective of ligament augmentation is to provide additional support to the upper levels of theconstruct (i.e., UIV+1, UIV, and UIV-1), reduce junctional stress at those levels, and reinforce the ligamentous complex. An illustration of the technique is shown in Fig. 18.2, with clinical example in Fig. 18.3. Using a high speed bur, a hole is drilled through the center of the spinous processes at the UIV, UIV+1, and UIV-1. A sublaminar cable is passed through these holes in a mirrored fashion, pulled taut on each side, and then fixed to the rod to maintain the desired amount of tension. The facet joint is left intact without adding significantly to intraoperative blood loss or operative time. This technique effectively creates a tension band loop encompassing the involved levels and adds strength to the upper construct while also providing a smooth transition from rigid fused levels to the more mobile segments above.
Fig. 18.2
Ligament augmentation. Using a matchstick burr, holes are drilled through the spinous processes of the UIV and the levels immediately above and below. A sublaminar cable is passed through each level in a stepwise fashion (a) then pulled to one side (b). The process is repeated with a second cable on the opposite side (c) then pulled down to obtain the desired amount of tension (d). The cables are then locked onto the rods on each side using supplied connectors (e)
Fig. 18.3
PJK/PJF prophylaxis using spinous process augmentation. Intraoperative photography demonstrating the Zimmer Universal Clamps (Zimmer Biomet Holdings, Inc.) applied as spinous process fixation devices. Drilled holes are created at the spino-laminar junction of the UIV +1, UIV, and UIV −1 levels. The bands on the clamps are passed through the drilled holes in a weave fashion in opposite directions to create a tension band loop encompassing the involved vertebral levels. The bands are tensioned and the clamps are secured to each of the main rods, effectively creating a functional posterior tension band
Illustrative Cases
Case 1
A 67-year-old female with scoliosis presented at age 65 with severe low back and leg pain. She had a thoracic kyphosis of 97° and was taken to the operating room for C7 to pelvis instrumented fusion with T8 vertebral column resection. She tolerated the procedure well, but 6 months later developed neck pain, heaviness, and inability to lift her head. Imaging revealed proximal junctional kyphosis/failure at C7 with severe cervical sagittal deformity (Fig. 18.4a, b). She was taken back to the operating room for extension of fusion to C2 with a C7 pedicle subtraction osteotomy. She tolerated this procedure well with improvement in her deformity (Fig.18.4c, d).
Fig. 18.4
Case 1 – proximal junctional kyphosis. Lateral cervical (a) and standing (b) X-rays showing proximal junctional kyphosis after prior C7-pelvis posterior instrumented fusion. The patient was taken to the operating room for extension of fusion to C2 with a C7 pedicle subtraction osteotomy resulting in resolution of her symptoms and improvement in her cervical deformity (c, d)
Case 2
A 58-year-old female presented after having undergone multiple prior spinal fusions including a T4–L4 posterior instrumented fusion. She was taken for T2-pelvis posterior instrumented fusion with L4–L5 and L5–S1 transforaminal interbody fusion. She presented 7 months later with severe back pain and inability to stand upright. Imaging revealed proximal junctional kyphosis (Fig. 18.5a, b). She was taken back to the operating room for a T1-pelvis posterior instrumented fusion with T4 vertebral column resection and T1–T3 ligament augmentation. She tolerated this procedure well with most recent imaging showing intact spinal implants without failure or proximal junctional kyphosis.
Fig. 18.5
Case 2 – proximal junctional kyphosis. Lateral cervical (a) and standing (b) X-rays showing proximal junctional kyphosis after a previous T2-pelvis posterior instrumented fusion. The patient developed proximal junctional kyphosis requiring extension of fusion to T1 with a T4 vertebral column resection and T1–T3 ligament augmentation. At last follow-up, her spinal implants were intact with improved cervical and sagittal alignment and resolution of her symptoms
Case 3
A 71-year-old female with scoliosis presented with debilitating back and leg pain. Preoperative imaging revealed a lumbar levoscoliosis, a pelvic incidence–lumbar lordosis mismatch of 30°, grade 1 spondylolisthesis at L5–S1, and 7.4 cm sagittal vertical axis (Fig. 18.6a, b). She was taken to the operating room for T10-pelvis posterior instrumented fusion with L1–S1 type one osteotomies along with T9–T10 vertebroplasty and T9–T11 ligament augmentation for proximal junctional kyphosis prevention. On last imaging at over 1 year after surgery, she was doing well with no evidence of proximal junctional kyphosis, fractures, or implant failure (Fig. 18.6c, d).
Fig. 18.6
Case 3 – proximal junctional kyphosis prevention strategies. A 71-year-old female with scoliosis presented with debilitating back and leg pain. Preoperative imaging revealed a 47° lumbar levoscoliosis, grade 1 spondylolisthesis at L5–S1, and 7.4 cm sagittal vertical axis (a, b). She was taken to the operating room for T10-pelvis posterior instrumented fusion with L1–S1 type one osteotomies and T9–T10 vertebroplasty and T9–T11 ligament augmentation for proximal junctional kyphosis prevention. On last imaging at over 1 year after surgery, she was doing well with no evidence of proximal junctional kyphosis, fractures, or implant failure (c, d)
Conclusion
PJK is a well-described complication following surgery for adult spinal deformity. Technical considerations in decreasing rates of PJK are critical to reducing the morbidity and cost associated with reoperations following initial deformity correction. Preservation of soft tissue above the fusion, terminal rod contouring, appropriate selection of the UIV, vertebroplasty, hook fixation, and ligament augmentation have the potential to reduce rates of PJK/PJF and should be considered in high-risk cases. Prospective studies are underway to further evaluate these strategies and their efficacy.
References
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Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine 2005;30(14):1643–9.
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Klineberg E, Schwab F, Ames C, et al. Acute reciprocal changes distant from the site of spinal osteotomies affect global postoperative alignment. Adv Orthop. 2011;2011:415946.CrossRefPubMedPubMedCentral
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