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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