Proper correction may reduce risk of proximal junctional failure
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A presenter at the Lumbar Spine Research Society Annual Instructional Course provided several surgical techniques and implants to consider in patients with adult spinal deformity to decrease the risk of proximal junctional failure.
According to Darrel S. Brodke, MD, to reduce the risk of proximal junctional failure, the construct should not end in lordosis or behind the sacrum, and surgeons should either begin or continue the thoracic kyphosis at the top levels. Surgeons should also choose an upper instrumented vertebra with a preoperative proximal junctional angle of less than 5°, according to Brodke.
“Do not fully correct to young adult, normal, sagittal balance in the elderly,” Brodke said in his presentation. “Normal is forward and, as a rough approximation, add about a centimeter per decade.”
Brodke noted previously published research showed overcorrection and no implant prophylaxis led to a higher incidence of proximal junctional failure. He added use of hooks in adult spinal deformity surgery had the lowest overall incidence of proximal junctional failure, while use of a tether at an upper instrumented vertebra plus one or plus two had a lower overall revision rate, Brodke noted.
“Cement augmentation seems to have good outcomes in retrospective studies,” Brodke said. “I have certainly revised patients for proximal junctional failure through cement, so it is not universally helpful.”
Brodke noted a number of studies reported good outcomes in adult spinal deformity surgery with the use of teriparatide or tension band augmentation with mersilene tape.
“There are some other ideas out there, and there will be more in the future,” Brodke said. “Dynamic stabilization in the top of a construct [and minimally invasive surgery] MIS at the top of the construct are two that we are looking at but may have some merit that, so far, have not borne out.”
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Brodke DS. Proximal junctional kyphosis/failure: Prevention and management. Presented at: Lumbar Spine Research Society Annual Instructional Course; Jan. 12, 19, 26, 2021 (virtual meeting).
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