Sagittal balance is more than just alignment: why PJK remains an unresolved problem
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RESEARCH
Open Access
Sagittal balance is more than just alignment: why PJK remains an unresolved problem Steven D. Glassman, Mark P. Coseo and Leah Y. Carreon*
Abstract Background: The durability of adult spinal deformity surgery remains problematic. Revision rates above 20 % have been reported, with a range of causes including wound infection, nonunion and adjacent level pathology. While some of these complications have been amenable to changes in patient selection or surgical technique, Proximal Junctional Kyphosis (PJK) remains an unresolved challenge. This study examines the contributions of non-mechanical factors to the incidence of postoperative sagittal imbalance and PJK after adult deformity surgery. Methods: We reviewed a consecutive series of adult spinal deformity patients who required revision for PJK from 2013 to 2015 and examined in their medical records in detail. Results: Neurologic disorders were identified in 22 (76 %) of the 29 PJK cases reviewed in this series. Neurologic disorders included Parkinson’s disease (1), prior stroke (5), metabolic encephalopathy (2), seizure disorder (1), cervical myelopathy (7), thoracic myelopathy (1), diabetic neuropathy (5) and other neuropathy (4). Other potential comorbidities affecting standing balance included untreated cataracts (9), glaucoma (1) and polymyositis (1). Eight patients were documented to have frequent falls, with twelve cases having a fall right before symptoms related to the PJK were noted. Conclusion: PJK is an important contributing factor to the substantial and unsustainable rate of revision surgery following adult deformity correction. Multiple efforts to avoid PJK via alterations in surgical technique have been largely unsuccessful. This study suggests that non-mechanical neuromuscular co-morbidities play an important role in post-operative sagittal imbalance and PJK. Recognizing the multi-factorial etiology of PJK may lead to more successful strategies to avoid PJK and improve surgical outcomes. Keywords: Adult spinal deformity, Adult scoliosis, Proximal junctional kyphosis, PJK
Background Surgical treatment of adult spinal deformity has progressed substantially over the past ten years. There have been significant advances in decision-making, medical management and surgical technique [1, 2]. These improvements in evaluation and treatment have broadened the applicability of adult deformity surgery and lead to more reproducible clinical benefit based upon health related quality of life (HRQOL) scores [3, 4]. Despite these positive developments, the durability of adult spinal deformity surgery remains problematic. * Correspondence: [email protected] Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, Kentucky 40202, USA
Revision rates above 20 % have been reported, with a range of causes including wound infection, nonunion and adjacent level pathology [5–7]. While some of these complications have been amenable to changes in patient selection or surgical technique, Proximal Junctional Kyphosis (P
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