Risk factors for radiographic progression of proximal junctional fracture in patients undergoing surgical treatment for adult spinal deformity.

OBJECTIVE: Proximal junctional fracture (PJFx) at the uppermost instrumented vertebra (UIV) or UIV+1 is the most common mechanism of proximal junctional failure (PJF). Few studies have assessed radiographic progression after PJFx development. Therefore, this study sought to identify the risk factors for radiographic progression of PJFx in the surgical treatment for adult spinal deformity. METHODS: In this retrospective study, among 317 patients aged > 60 years who underwent ≥ 5-level fusion from the sacrum, 76 with PJFx development were included. On the basis of the change in the proximal junctional angle (PJA), 2 groups were created: progression group (group P) (change ≥ 10°) and nonprogression group (group NP) (change < 10°). Patient, surgical, and radiographic variables were compared between the groups with univariate and multivariate analyses to demonstrate the risk factors for PJFx progression. The receiver operating characteristic (ROC) curve was used to calculate cutoff values. Clinical outcomes, such as visual analog scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI) score, the Scoliosis Research Society (SRS)-22 score, and the revision rate were compared between the 2 groups. RESULTS: The mean age at index surgery was 71.1 years, and 67 women were enrolled in the study (88.2%). There were 45 patients in group P and 31 in group NP. The mean increase in PJA was 15.6° (from 23.2° to 38.8°) in group P and 3.7° (from 17.2° to 20.9°) in group NP. Clinical outcomes were significantly better in group NP than group P, including VAS-back score, ODI score, and SRS-22 scores for all items. The revision rate was significantly greater in group P than in group NP (53.3% vs 25.8%, p = 0.001). Multivariate analysis revealed that overcorrection relative to the age-adjusted ideal pelvic incidence (PI)-lumbar lordosis (LL) target at index surgery (OR 4.484, p = 0.030), PJA at the time of PJFx identification (OR 1.097, p = 0.009), and fracture at UIV (vs UIV+1) (OR 3.410, p = 0.027) were significant risk factors for PJFx progression. The cutoff value of PJA for PJFx progression was calculated as 21° by using the ROC curve. CONCLUSIONS: The risk factors for further progression of PJFx were overcorrection relative to the age-adjusted PI-LL target at index surgery, PJA > 21° at initial presentation, and fracture at the UIV level. Close monitoring is warranted for such patients in order to not miss timely revision surgery.

Long-term Radiographic and Clinical Outcomes After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis With Lenke 1C Curve.

BACKGROUND: Despite the promising results with selective thoracic fusion (STF) in patients with adolescent idiopathic scoliosis (AIS) of the Lenke 1C curve, postoperative coronal imbalance and progression of the unfused lumbar curve have been concerns in long-term follow-up. In this study, we aimed to investigate the radiographic and clinical outcomes after STF for AIS with Lenke 1C curve with long-term follow-up. METHODS: A total of 30 patients with AIS with Lenke 1C curves who underwent STF between 2005 and 2017 were included. Minimum follow-up duration was 5 years. Time-dependent changes in radiographic parameters were investigated preoperatively, immediately postoperatively, and at the last follow-up. In addition, radiographic adverse events such as coronal decompensation (CD), lumbar decompensation (LD), distal adding-on (DA) phenomenon, and trunk shift were evaluated at the last follow-up. The Scoliosis Research Society-22 score was used for clinical outcome evaluation. RESULTS: The mean age at the time of surgery was 13.8 years. The mean follow-up duration was 6.7 ± 0.8 years. The main thoracic curve significantly improved from 57 degrees to 23 degrees (60% correction), and the thoracolumbar/lumbar curve significantly improved from 47 degrees to 28 degrees (41% correction). Coronal balance was 15 mm after surgery but significantly improved to 10 mm at the last follow-up ( P = 0.033). At the final follow-up, 11 patients (37%) sustained at least one of the radiographic adverse events: CD in 5 patients (17%), LD in 3 (10%), DA in 4 (13%), and trunk shift in 3 (10.%). However, there were no cases requiring revision surgery. In addition, there were no significant differences in any items or total Scoliosis Research Society-22 score between the patients with and without radiographic adverse events. CONCLUSION: STF in Lenke 1C curves showed an acceptable risk of adverse radiographic events such as CD, LD, DA, and trunk shift in long-term follow-up. We suggest that STF without fusion to the thoracolumbar/lumbar curve would be sufficient in treating AIS with Lenke 1C curve. LEVEL OF EVIDENCE: Level III.

A Validation Study of Four Preoperative Surgical Planning Tools for Adult Spinal Deformity Surgery in Proximal Junctional Kyphosis and Clinical Outcomes.

BACKGROUND: Four guidelines have been suggested for optimal correction in adult spinal deformity surgery: Scoliosis Research Society (SRS)-Schwab classification, age-adjusted sagittal alignment goals, Global Alignment and Proportion (GAP) score, and the Roussouly algorithm. Whether these goals provide benefit in both proximal junctional kyphosis (PJK) reduction and clinical outcome improvement remains unclear. OBJECTIVE: To validate 4 preoperative surgical planning tools in PJK development and clinical outcomes. METHODS: We retrospectively reviewed patients who underwent ≥5-segment fusion including the sacrum for adult spinal deformity with a follow-up of ≥2-year. PJK development and clinical outcomes were compared among the groups separately using 4 surgical guidelines: SRS-Schwab pelvic incidence (PI)-lumbar lordosis (LL) modifier (Group 0, +, ++), age-adjusted PI-LL goal (undercorrection, matched correction, and overcorrection), GAP score (proportioned, moderately disproportioned, and severely disproportioned groups), and the Roussouly algorithm (restored and nonrestored groups). RESULTS: A total of 189 patients were included in this study. The mean age was 68.3 years, and there were 162 women (85.7%). There were no differences in the rate of PJK development and clinical outcomes among SRS-Schwab PI-LL modifier and GAP score groups. With the age-adjusted PI-LL goal, PJK developed significantly less frequently in the matched group compared with the under- and overcorrection groups. Clinical outcomes were significantly better in the matched group compared with the under- and overcorrection groups. With the Roussouly algorithm, PJK developed significantly less frequently in the restored group than in the nonrestored group. However, there were no differences in clinical outcomes between the 2 Roussouly groups. CONCLUSION: Correction according to the age-adjusted PI-LL goal and the restored Roussouly type was associated with reduced PJK development. However, differences in clinical outcomes were only observed in the age-adjusted PI-LL groups.

Survival and Functional Outcomes after Surgical Treatment for Spinal Metastasis in Patients with a Short Life Expectancy.

This study aimed to analyze the survival and functional outcome after surgery in spinal metastasis patients with a short life expectancy and to compare the baseline characteristics based on 3-month survival. A total of 492 surgical treatment cases with a preoperative revised Tokuhashi score ≤ 8were reviewed. Median survival was calculated and Kaplan−Meier analysis was used to analyze the survival rates at 6 months, 1 year, and 2 years postoperatively. The surgical period was divided into three time frames to examine the time trends. For the functional outcome, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was analyzed. This study categorized subjects based on 3-month survival and compared the baseline characteristics. The median overall survival was 10.6 months. The 2013−2020 period showed a significantly better median survival than the other two periods (p < 0.001). Lung and kidney cancers showed a significant survival improvement in 2013−2020 (p < 0.001). Patients with ECOG-PS ≤ 2 increased from 37.4% preoperatively to 63.7% postoperatively (p < 0.001). There were significantly more cases of preoperative favorable performance status, slow and moderate growth cancers, and chemotherapy after surgery in the survival ≥3 months group. Depending on the type of primary cancer, surgery can be considered even in spinal metastasis patients with a short life expectancy, particularly those with a good performance status.

Prevention of Adjacent Segmental Disease after Fusion in Degenerative Spinal Disorder: Correlation between Segmental Lumbar Lordosis Ratio and Pelvic Incidence-Lumbar Lordosis Mismatch for a Minimum 5-Year Follow-up.

Study Design: Retrospective study. Purpose: Associations among risk factors related to adjacent segmental disease (ASD) remain unclear. We evaluated the risk factors and segmental lordosis ratio to prevent ASD developing after lumbar spinal fusion. Overview of Literature: Risk factors related to ASD development are age, sex, obesity, pre-existing degeneration, number of fusion segments, and decreased postoperative lumbar lordosis (LL). However, the associations among these factors are still unclear and should be clearly identified. Methods: We retrospectively reviewed data on 274 patients who underwent lumbar spinal fusion of three segments or below for lumbar degenerative disease from January 2010 to December 2012, with over 5 years of follow-up. Patients with preoperative sagittal vertical axis (SVA) >5 cm were excluded due to sagittal imbalance. A total of 37 patients with ASD and 40 control patients (CTRL) were randomly selected in a similar distribution of matching variables: age, sex, and preoperative degenerative changes. Sex, age, number of fusion segments, radiologic measurements, L4-5-S1/L1-S1 LL ratio, and spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and SVA) were analyzed. Logistic regression was used to analyze the correlation between PI-LL mismatch and L4-5-S1 segmental lordosis rate. Results: No significant difference was found between ASDs and CTRL groups regarding age, sex, number of fusion segments, fusion method, and preoperative and postoperative spinopelvic parameters (PI, SS, PT, and LL). However, regarding the L4-5-S1/L1-S1 lordosis ratio, 50% (p=0.045), 60% (p=0.031), 70% (p=0.042), 80% (p=0.023), and 90% (p=0.023) were statistically significant; <20% (p=0.478), 30% (p=0.223), and 40% (p=0.089) were not statistically significant. In the postoperative PI-LL <10 group, ASD occurred less frequently than in the PI-LL >10 group, and the difference was statistically significant (p=0.048). Conclusions: Patients with a postoperative L4-5-S1/L1-S1 lordosis ratio >50% had less occurrence of ASD. Correcting LL according to PI and physiologic segmental lordosis ratio is important in preventing ASD.

Clinical and Radiologic Outcomes After Medializing and Not Medializing Rotator Cuff Tendon Attachment Site on Chronic Retracted Rotator Cuff Tears.

PURPOSE: To compare the clinical and radiologic outcomes of chronically retracted rotator cuff tears by arthroscopic medializing and non-medializing repair (restoring anatomic footprint and performing conventional repair). METHODS: This study retrospectively reviewed 195 patients who underwent arthroscopic double-row modified Mason-Allen repair for large, full-thickness rotator cuff tears from January 2013 to July 2015. We included a total of 60 of these patients and divided them into 2 groups: those who underwent medialization (n = 24) and those who did not (n = 36). Magnetic resonance imaging was performed at a minimum of 6 months (mean, 15.2 months; range, 6-24 months) postoperatively to assess cuff integrity. Patients were clinically evaluated at least 1 year postoperatively (mean, 18.9 months; range, 12-60 months) with a visual analog scale, the American Shoulder and Elbow Surgeons score, the University of California-Los Angeles Shoulder Rating Scale score, and the Constant score. RESULTS: The mean medialization length was 10.5 mm (range, 6.5-15.6 mm) on magnetic resonance imaging. The retear rate was 8.3% (n = 2) in the medialization group and 31% (n = 11) in the non-medialization group (P = .041). At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons, University of California-Los Angeles, and Constant scores improved significantly from 5.3 ± 1.4, 38.5 ± 8.8, 22.5 ± 3.1, and 41.7 ± 9.9, respectively, to 1.8 ± 1.1, 85.3 ± 7.5, 31.8 ± 2.5, and 90.2 ± 6.9, respectively, with medialization and from 4.0 ± 1.6, 51.5 ± 10.5, 20.0 ± 3.9, and 55.9 ± 10.5, respectively, to 1.4 ± 1.0, 88.6 ± 9.0, 31.0 ± 9.3, and 89.4 ± 9.3, respectively, with non-medialization (P < .001), although there were no significant differences between the groups (P = .165, P = .653, P = .250, and P = .113, respectively). CONCLUSIONS: Medialization of approximately 10.5 mm reliably shows good clinical results, and medializing rotator cuff tendons should be considered as a treatment option for repairing rotator cuff tears with chronic retracted tendons. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical outcomes and repair integrity after arthroscopic full-thickness rotator cuff repair: suture-bridge versus double-row modified Mason-Allen technique.

BACKGROUND: This retrospective study compared the clinical and radiologic outcomes of patients who underwent arthroscopic rotator cuff repairs by the suture-bridge and double-row modified Mason-Allen techniques. METHODS: From January 2012 to May 2013, 76 consecutive cases of full-thickness rotator cuff tear, 1 to 4 cm in the sagittal plane, for which arthroscopic rotator cuff repair was performed, were included. The suture-bridge technique was used in 37 consecutive shoulders; and the double-row modified Mason-Allen technique, in 39 consecutive shoulders. Clinical outcomes at a minimum of 2 years (mean, 35.7 months) were evaluated postoperatively using the visual analog scale; University of California, Los Angeles Shoulder Scale; American Shoulder and Elbow Surgeons Subjective Shoulder Scale; and Constant score. Postoperative cuff integrity was evaluated at a mean of 17.7 months by magnetic resonance imaging. RESULTS: At the final follow-up, the clinical outcomes improved in both groups (all P < .001) but with no significant differences between the 2 groups (all P > .05). The retear rate was 18.9% in the shoulders subjected to suture-bridge repair and 12.8% in the double-row modified Mason-Allen group; the difference was not significant (P = .361). CONCLUSIONS: Despite the presence of fewer suture anchors, the patients who underwent double-row modified Mason-Allen repair had comparable shoulder functional outcomes and a comparable retear rate with those who underwent suture-bridge repair. Therefore, the double-row modified Mason-Allen repair technique can be considered an effective treatment for patients with medium- to large-sized full-thickness rotator cuff tears.