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Prevention of PJF: Surgical Strategies to Reduce PJF
Robert Hart, MD
Professor
OHSU Orthopaedics
Portland OR
Conflicts
Consultant Depuy Spine, Medtronic
Royalties Seaspine, Depuy
Research/Fellowship Support Depuy, Medtronic, Synthes, OREF, MRF, ISSG
Board Member, ISSLS and CSRS
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Proximal Junctional Failure
What is it?
What are the risk factors?
What are the mechanisms?
How can it be prevented?
What is Proximal Junctional Failure?
Fracture and/or Soft Tissue Disruption at Upper Instrumented or Next Adjacent Segment Following
Long Instrumented Fusion
Distinct from
“Proximal Junctional Kyphosis”
“Topping Off Syndrome”
Proximal Junctional Fracture
Fracture above all Pedicle Screw Construct
(FPSC)
Proximal Junctional Acute
Collapse
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Increasingly Recognized and Described Following Long
Lumbar Spine Fusions
Etebar and Cahill, J Neurosurg, 90:163-9, 1999
Dewald and Stanley, Spine, 31:S144-51, 2006
Hart et al., TSJ, 8:875-81, 2008
Kim et al., Spine, 32:2653-61, 2007
O’Leary et al., Spine, 34:2134-9, 2009
Watanabe et al., Spine, 35:138-45, 2010
Recent Estimates of Incidence
Lau, D et al, SRS Adult Deformity Comm, Spine, 2014
Incidence 5-46%; Revision Rates 13-55%
Bridwell et al, Neurosurgery, 2013
Prevalence 39.5%, Worsened SRS Pain Scores
Maruo et al, Spine, 2013
Incidence 41%, Revision Rate 13%
Hostin et al, ISSG, Spine, 2013
5.6% Incidence of PJF
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Case Example 3: 70 yo Woman S/P Laminectomy PSF L2-L5
What Are the Risk Factors?
Age
Preop Sagittal Imbalance
Use of PSO for Correction
Operative Change in LL and PI-LL
Distal Fusion to Sacrum
Hart/ISSG, IMAST, 2012
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Verification of Risk Factors
Maruo et al, Spine, 2013
Kim et al, Spine, 2014
Lau et al, Spine, 2014
Other Possible Risk Factors:
High BMI
Low Bone Density
Medical Comorbidities
Proximal End Point
What Are the Failure Mechanisms?
Anterior Vertebral Collapse
Hardware Pullout
Posterior Column Disruption
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Proximal Junctional Failure Severity Score PJFSS
1) Neurological Deficit
None 0 pt Radicular Pain 2 pt Myelopathy/Weakness 4 pt
2) Focal Pain
None 0 pt VAS 4 or Less 1 pt VAS >= 5 3 pt
3) Instrumentation Problem
None 0 pt Partial Fixation Loss 1 pt Prominence 1 pt Complete Fixation Loss 2 pt
4) Change in Kyphosis/PLC Integrity
0 – 10 Degrees 0 pt 10-20 Degress 1 pt >20 Degrees 2 pt PLC Failure 2 pt
5) UIV/UIV+1 Fracture
None 0 pt Compression Fx 1 pt. Burst/Chance Fracture 2 pt. Translation 3 pt.
6) Level of UIV
TL Junction 0 pt Upper Thoracic 1 pt
SRS 2013,2014
Importance of Posterior Column Failure
No Translation
No Hardware Failure
Lower Kyphosis
Lower Risk of Neurological Injury
Lower Revision Rate
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Case Example 1: 70 YO Woman 1 Level TLIF
2 Year Follow-up Fracture T10 (UIV) “Reciprocal Change”
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Described Preventive Techniques
• Vertebral Augmentation • Proximal Hooks
• Moving Junction Cranial • “Tuning” Correction
• “Laying In” Rods to Upper Screws • Limit Proximal Dissection
Described Preventive Techniques
• Vertebral Augmentation • Proximal Hooks
• Moving Junction Cranial • “Tuning” Correction
• “Laying In” Rods to Upper Screws • Limit Proximal Dissection
Limited Data to Support Any of
These
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Case Example
73 YO Woman Degenerative
S/P Laminectomy
Tuning Correction Vertebral Augmentation
PI = 65.0 T12-S1 LL = 66.6
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2 Years Postop
Marked PJK with
DJD at Proximal Disk
Upper Thoracic Junction Proximal Hooks
Fusion Extended to T3 With TP Hooks
2.5 Years Post Index
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4 Months Postop
T3 PJF Pull Out of TP Hooks
Second Revision
Extended to C4 3 Years 10 Mos
Post Index
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Let’s Get Back to the Posterior Column
None of these Techniques Augment
Posterior Column Integrity MAY Be Key
What Techniques Are Available?
Posterior Column Augmentation
Spinous Process Augmentation
Rib Fixation
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UIV+1 Rib Fixation
Proximal UIV+1 Rib Fixation
Reduces Proximal Dissection –
Good Biological Sense
Extends Moment Arm Lateral –
Good Mechanical Sense
Allows Other Surgical Techniques
Some OR Fuss
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Rib Fixation Technique
Rib Attachment
UIV+1 Level
Separate Lateral Incisions
Blunt Muscle Dissection
Offset Connection
Include Suture Reenforcment of SP’s
Experience
26 patients (6 M/20 F)
Mean age of 68.1 years (range 54-80)
16 Metal, 10 Soft Tether
2 Rigid Thoracic Kyphosis
5 Prior PJF/PJK
2 Postural Kyphosis with Parkinson’s
13 DEXA scans: 2 Osteoporotic, 5 Osteopenic
Mean SVA = 96.7 mm
Mean PI-LL = 21.8 degrees
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Sagittal Realignment
Mean Sagittal Vertical Axis improved from
128 mm positive imbalance to 38mm
(Pelvic Incidence - Lumbar Lordosis)
improved from 30.9˚ to 11.5˚
24/26 Fused to Sacro-Pelvis
Pulmonary Complications
1 Pneumonia
1 Air Leak
1 Pulmonary Embolus (Fatality)
5 PJF/3 PJF (19.2 and 11.5%)
NO Revisions for PJF/PJK
PJF Results
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67 YO Woman BMI 42
Osteopenia Multiple Prior Surg
Case Example
Nearing 2 Year FU T4-Pelvis Fusion 2 Stage VCR L3
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Conclusions
PJF is a Serious Complication
Risk Profile Defined
Methods to Reduce Frequency
No Technique Proven to Eliminate PJF
Ultimate Solution Likely Multi-Pronged
Posterior Column Augmentation Holds Promise
THANK YOU