Application of back-forward Bending CT localization image in the prediction of proximal junctional kyphosis after spinal deformity surgery in adults_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Rui ,  YU Haiyang , ZHANG Wei , CHAI Zihao , ZHENG Guohui , HU Xiaoming , ZHANG Haoran , LU Haitao

Department of Orthopedics, Fuyang People’s Hospital Affiliated to Anhui Medical University (Fuyang People’s Hospital), Anhui Clinical Research Center for Spinal Deformity, Fuyang Anhui, 236000, P. R. China;

Corresponding?author：

YU Haiyang, Email: fy.yhy@163.com

Keywords：

Back-forward Bending CT localization image; adult spinal deformity; long-segment fusion fixation; proximal junctional kyphosis

DOI：

10.7507/1002-1892.202212079

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Objective To investigate the feasibility of predicting proximal junctional kyphosis (PJK) in adults after spinal deformity surgery based on back-forward Bending CT localization images and related predictive indicators. Methods A retrospective analysis was performed for 31 adult patients with spinal deformity who underwent posterior osteotomy and long-segment fusion fixation between March 2017 and March 2020. There were 5 males and 26 females with an average age of 62.5 years (range, 30-77 years). The upper instrumented vertebrae (UIV) located at T₅ in 1 case, T₆ in 1 case, T₉ in 13 cases, T₁₀ in 12 cases, and T₁₁ in 4 cases. The lowest instrumented vertebrae (LIV) located at L₁ in 3 cases, L₂ in 3 cases, L₃ in 10 cases, L₄ in 7 cases, L₅ in 5 cases, and S₁ in 3 cases. Based on the full-length lateral X-ray film of the spine in the standing position before and after operation and back-forward Bending CT localization images before operation, the sagittal sequence of the spine was obtained, and the relevant indexes were measured, including thoracic kyphosis (TK), lumbar lordosis (LL), local kyphosis Cobb angle (LKCA) [the difference between the different positions before operation (recovery value) was calculated], kyphosis flexibility, hyperextension sagittal vertical axis (hSVA), T₂-L₅ hyperextension C₇-vertebral sagittal offset (hC₇-VSO), and pre- and post-operative proximal junctional angle (PJA). At last follow-up, the patients were divided into PJK and non-PJK groups based on PJA to determine whether they had PJK. The gender, age, body mass index (BMI), number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, osteotomy grading, and related imaging indicators were compared between the two groups. The hC₇-VSO of the vertebral body with significant differences between groups was taken, and the receiver operating characteristic curve (ROC) was used to evaluate its accuracy in predicting the occurrence of PJK. Results All 31 patients were followed up 13-52 months, with an average of 30.0 months. The patient’s PJA was 1.4°-29.0° at last follow-up, with an average of 10.4°; PJK occurred in 8 cases (25.8%). There was no significant difference in gender, age, BMI, number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, and osteotomy grading between the two groups (P>0.05). Imaging measurements showed that the LL recovery value and T₈-L₃ vertebral hC₇-VSO in the PJK group were significantly higher than those in the non-PJK group (P>0.05). There was no significant difference in hyperextension TK, hyperextension LL, hyperextension LKCA, TK recovery value, LL recovery value, kyphosis flexibility, hSVA, and T₂-T₇, L₄, L₅ vertebral hC₇-VSO (P>0.05). T₈-L₃ vertebral hC₇-VSO was analyzed for ROC curve, and combined with the area under curve and the comprehensive evaluation of sensitivity and specificity, the best predictive index was hC₇-L₂, the cut-off value was 2.54 cm, the sensitivity was 100%, and the specificity was 60.9%. Conclusion Preoperative back-forward Bending CT localization image can be used to predict the occurrence of PJK after posterior osteotomy and long-segment fusion fixation in adult spinal deformity. If the patient’s T₈-L₂ vertebral hC₇-VSO is too large, it indicates a higher risk of postoperative PJK. The best predictive index is hC₇-L₂, and the cut-off value is 2.54 cm.

Citation： ZHAO Rui, YU Haiyang, ZHANG Wei, CHAI Zihao, ZHENG Guohui, HU Xiaoming, ZHANG Haoran, LU Haitao. Application of back-forward Bending CT localization image in the prediction of proximal junctional kyphosis after spinal deformity surgery in adults. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(5): 589-595. doi: 10.7507/1002-1892.202212079 Copy

1.	張迪, 張文明, 周獻偉, 等. 骨水泥螺釘聯合多節段SchwabⅠ級截骨治療陳舊性胸腰椎骨質疏松性骨折伴后凸畸形. 中國修復重建外科雜志, 2020, 34(12): 1533-1538.
2.	Wen Z, Mo X, Zhao S, et al. Comparison of percutaneous kyphoplasty and pedicle screw fixation for treatment of thoracolumbar severe osteoporotic vertebral compression fracture with kyphosis. World Neurosurg, 2021, 152: e589-e596.
3.	Diebo BG, Shah NV, Stroud SG, et al. Realignment surgery in adult spinal deformity: Prevalence and risk factors for proximal junctional kyphosis. Orthopade, 2018, 47(4): 301-309.
4.	胡曉明, 于海洋, 鄭國輝, 等. 陳舊性胸腰椎骨折后凸畸形術后近端交界性后凸發生的危險因素及生活質量研究. 實用骨科雜志, 2022, 28(7): 577-583.
5.	Luo M, Wang P, Wang W, et al. Upper thoracic versus lower thoracic as site of upper instrumented vertebrae for long fusion surgery in adult spinal deformity: A meta-analysis of proximal junctional kyphosis. World Neurosurg, 2017, 102: 200-208.
6.	Xi Z, Duan PG, Mummaneni PV, et al. Posterior displacement of L1 may be a risk factor for proximal junctional kyphosis after adult spinal deformity correction. Global Spine J, 2021. doi: 10.1177/21925682211015651.
7.	張鑫, 鮑虹達, 舒詩斌, 等. 頸2-股骨頭中心位移和骶髂固定對成人脊柱畸形術后近端交界性后凸發生的影響研究. 中華醫學雜志, 2022, 102(19): 1458-1463.
8.	Rodnoi P, Le H, Hiatt L, et al. Ligament augmentation with mersilene tape reduces the rates of proximal junctional kyphosis and failure in adult spinal deformity. Neurospine, 2021, 18(3): 580-586.
9.	Amaral R, Daher MT, Pratali R, et al. The effect of patient position on psoas morphology and in lumbar lordosis. World Neurosurg, 2021, 153: e131-e140.
10.	Wessels L, Komm B, Bohner G, et al. Spinal alignment shift between supine and prone CT imaging occurs frequently and regardless of the anatomic region, risk factors, or pathology. Neurosurg Rev, 2022, 45(1): 855-863.
11.	Weisz GM, Albury WR, Houang MD, et al. Scanogram for sagittal imbalance of the spine: low dose alternative for a safer diagnosis. Curr Rheumatol Rev, 2014, 10(1): 35-37.
12.	崔西龍, 李貝貝, 張偉, 等. 俯臥位加壓CT定位像在無神經癥狀胸腰段骨折畸形愈合繼發后凸畸形矯形術中的意義. 頸腰痛雜志, 2021, 42(4): 451-454.
13.	張旭, 于海洋, 梁成民, 等. 俯臥位脊柱全長加壓CT檢查在骨質疏松性脊柱骨折伴后凸畸形治療中的作用. 中國脊柱脊髓雜志, 2018, 28(6): 516-521.
14.	張子方, 鄭國權, 薛超, 等. 成人脊柱畸形矯形術后早期軀體重心線(W-line)與近端交界區失敗的相關性分析. 中國脊柱脊髓雜志, 2022, 32(3): 221-229.
15.	Glattes RC, Bridwell KH, Lenke LG, et al. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976), 2005, 30(14): 1643-1649.
16.	Schwab F, Blondel B, Chay E, et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery, 2015, 76 Suppl 1: S33-S41.
17.	Zhao J, Yang M, Yang Y, et al. Proximal junctional kyphosis in adult spinal deformity: a novel predictive index. Eur Spine J, 2018, 27(9): 2303-2311.
18.	Kikuchi K, Miyakoshi N, Abe E, et al. Proximal junctional fracture and kyphosis after long spinopelvic corrective fixation for adult spinal deformity. J Orthop Sci, 2021, 26(3): 343-347.
19.	張坤坤, 于海洋, 梁成民, 等. 俯臥位脊柱全長加壓CT檢查在陳舊性骨質疏松性脊柱骨折伴中重度后凸畸形中的作用. 頸腰痛雜志, 2021, 42(3): 313-317.
20.	Langensiepen S, Semler O, Sobottke R, et al. Measuring procedures to determine the Cobb angle in idiopathic scoliosis: a systematic review. Eur Spine J, 2013, 22(11): 2360-2371.
21.	孫卓然, 姜帥, 鄒達, 等. 國人青年人群坐-立位脊柱-骨盆矢狀位序列變化研究. 中國脊柱脊髓雜志, 2018, 28(4): 325-329.
22.	Ryan N, Bruno P. Analysis of 3D multi-segment lumbar spine motion during gait and prone hip extension. J Electromyogr Kinesiol, 2017, 33: 111-117.
23.	Kim HJ, Alluri RK, Lafage R, et al. Upper versus lower lumbar lordosis corrections in relation to pelvic tilt—An essential element in surgical planning for sagittal plane deformity. Spine (Phila Pa 1976), 2022, 47(16): 1145-1150.
24.	Maruo K, Ha Y, Inoue S, et al. Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity. Spine (Phila Pa 1976), 2013, 38(23): E1469-E1476.
25.	Hyun SJ, Kim YJ, Rhim SC. Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area. Spine J, 2016, 16(9): 1095-1101.
26.	李清萍, 郭安娜, 陳少卿, 等. 基于鉛垂線觀察脊柱矢狀面平衡的可行性. 脊柱外科雜志, 2020, 18(3): 184-187.
27.	Kim DK, Kim JY, Kim DY, et al. Risk factors of proximal junctional kyphosis after multilevel fusion surgery: More than 2 years follow-up data. J Korean Neurosurg Soc, 2017, 60(2): 174-180.

1. 張迪, 張文明, 周獻偉, 等. 骨水泥螺釘聯合多節段SchwabⅠ級截骨治療陳舊性胸腰椎骨質疏松性骨折伴后凸畸形. 中國修復重建外科雜志, 2020, 34(12): 1533-1538.
2. Wen Z, Mo X, Zhao S, et al. Comparison of percutaneous kyphoplasty and pedicle screw fixation for treatment of thoracolumbar severe osteoporotic vertebral compression fracture with kyphosis. World Neurosurg, 2021, 152: e589-e596.
3. Diebo BG, Shah NV, Stroud SG, et al. Realignment surgery in adult spinal deformity: Prevalence and risk factors for proximal junctional kyphosis. Orthopade, 2018, 47(4): 301-309.
4. 胡曉明, 于海洋, 鄭國輝, 等. 陳舊性胸腰椎骨折后凸畸形術后近端交界性后凸發生的危險因素及生活質量研究. 實用骨科雜志, 2022, 28(7): 577-583.
5. Luo M, Wang P, Wang W, et al. Upper thoracic versus lower thoracic as site of upper instrumented vertebrae for long fusion surgery in adult spinal deformity: A meta-analysis of proximal junctional kyphosis. World Neurosurg, 2017, 102: 200-208.
6. Xi Z, Duan PG, Mummaneni PV, et al. Posterior displacement of L1 may be a risk factor for proximal junctional kyphosis after adult spinal deformity correction. Global Spine J, 2021. doi: 10.1177/21925682211015651.
7. 張鑫, 鮑虹達, 舒詩斌, 等. 頸2-股骨頭中心位移和骶髂固定對成人脊柱畸形術后近端交界性后凸發生的影響研究. 中華醫學雜志, 2022, 102(19): 1458-1463.
8. Rodnoi P, Le H, Hiatt L, et al. Ligament augmentation with mersilene tape reduces the rates of proximal junctional kyphosis and failure in adult spinal deformity. Neurospine, 2021, 18(3): 580-586.
9. Amaral R, Daher MT, Pratali R, et al. The effect of patient position on psoas morphology and in lumbar lordosis. World Neurosurg, 2021, 153: e131-e140.
10. Wessels L, Komm B, Bohner G, et al. Spinal alignment shift between supine and prone CT imaging occurs frequently and regardless of the anatomic region, risk factors, or pathology. Neurosurg Rev, 2022, 45(1): 855-863.
11. Weisz GM, Albury WR, Houang MD, et al. Scanogram for sagittal imbalance of the spine: low dose alternative for a safer diagnosis. Curr Rheumatol Rev, 2014, 10(1): 35-37.
12. 崔西龍, 李貝貝, 張偉, 等. 俯臥位加壓CT定位像在無神經癥狀胸腰段骨折畸形愈合繼發后凸畸形矯形術中的意義. 頸腰痛雜志, 2021, 42(4): 451-454.
13. 張旭, 于海洋, 梁成民, 等. 俯臥位脊柱全長加壓CT檢查在骨質疏松性脊柱骨折伴后凸畸形治療中的作用. 中國脊柱脊髓雜志, 2018, 28(6): 516-521.
14. 張子方, 鄭國權, 薛超, 等. 成人脊柱畸形矯形術后早期軀體重心線(W-line)與近端交界區失敗的相關性分析. 中國脊柱脊髓雜志, 2022, 32(3): 221-229.
15. Glattes RC, Bridwell KH, Lenke LG, et al. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976), 2005, 30(14): 1643-1649.
16. Schwab F, Blondel B, Chay E, et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery, 2015, 76 Suppl 1: S33-S41.
17. Zhao J, Yang M, Yang Y, et al. Proximal junctional kyphosis in adult spinal deformity: a novel predictive index. Eur Spine J, 2018, 27(9): 2303-2311.
18. Kikuchi K, Miyakoshi N, Abe E, et al. Proximal junctional fracture and kyphosis after long spinopelvic corrective fixation for adult spinal deformity. J Orthop Sci, 2021, 26(3): 343-347.
19. 張坤坤, 于海洋, 梁成民, 等. 俯臥位脊柱全長加壓CT檢查在陳舊性骨質疏松性脊柱骨折伴中重度后凸畸形中的作用. 頸腰痛雜志, 2021, 42(3): 313-317.
20. Langensiepen S, Semler O, Sobottke R, et al. Measuring procedures to determine the Cobb angle in idiopathic scoliosis: a systematic review. Eur Spine J, 2013, 22(11): 2360-2371.
21. 孫卓然, 姜帥, 鄒達, 等. 國人青年人群坐-立位脊柱-骨盆矢狀位序列變化研究. 中國脊柱脊髓雜志, 2018, 28(4): 325-329.
22. Ryan N, Bruno P. Analysis of 3D multi-segment lumbar spine motion during gait and prone hip extension. J Electromyogr Kinesiol, 2017, 33: 111-117.
23. Kim HJ, Alluri RK, Lafage R, et al. Upper versus lower lumbar lordosis corrections in relation to pelvic tilt—An essential element in surgical planning for sagittal plane deformity. Spine (Phila Pa 1976), 2022, 47(16): 1145-1150.
24. Maruo K, Ha Y, Inoue S, et al. Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity. Spine (Phila Pa 1976), 2013, 38(23): E1469-E1476.
25. Hyun SJ, Kim YJ, Rhim SC. Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area. Spine J, 2016, 16(9): 1095-1101.
26. 李清萍, 郭安娜, 陳少卿, 等. 基于鉛垂線觀察脊柱矢狀面平衡的可行性. 脊柱外科雜志, 2020, 18(3): 184-187.
27. Kim DK, Kim JY, Kim DY, et al. Risk factors of proximal junctional kyphosis after multilevel fusion surgery: More than 2 years follow-up data. J Korean Neurosurg Soc, 2017, 60(2): 174-180.

Chinese Journal of Reparative and Reconstructive Surgery

Application of back-forward Bending CT localization image in the prediction of proximal junctional kyphosis after spinal deformity surgery in adults

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