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.	张迪, 张文明, 周献伟, 等. 骨水泥螺钉联合多节段SchwabⅠ级截骨治疗陈旧性胸腰椎骨质疏松性骨折伴后凸畸形. 中国修复重建外科杂志, 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.	胡晓明, 于海洋, 郑国辉, 等. 陈旧性胸腰椎骨折后凸畸形术后近端交界性后凸发生的危险因素及生活质量研究. 实用骨科杂志, 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.	张鑫, 鲍虹达, 舒诗斌, 等. 颈2-股骨头中心位移和骶髂固定对成人脊柱畸形术后近端交界性后凸发生的影响研究. 中华医学杂志, 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.	崔西龙, 李贝贝, 张伟, 等. 俯卧位加压CT定位像在无神经症状胸腰段骨折畸形愈合继发后凸畸形矫形术中的意义. 颈腰痛杂志, 2021, 42(4): 451-454.
13.	张旭, 于海洋, 梁成民, 等. 俯卧位脊柱全长加压CT检查在骨质疏松性脊柱骨折伴后凸畸形治疗中的作用. 中国脊柱脊髓杂志, 2018, 28(6): 516-521.
14.	张子方, 郑国权, 薛超, 等. 成人脊柱畸形矫形术后早期躯体重心线(W-line)与近端交界区失败的相关性分析. 中国脊柱脊髓杂志, 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.	张坤坤, 于海洋, 梁成民, 等. 俯卧位脊柱全长加压CT检查在陈旧性骨质疏松性脊柱骨折伴中重度后凸畸形中的作用. 颈腰痛杂志, 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.	孙卓然, 姜帅, 邹达, 等. 国人青年人群坐-立位脊柱-骨盆矢状位序列变化研究. 中国脊柱脊髓杂志, 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, 陈少卿, 等. 基于铅垂线观察脊柱矢状面平衡的可行性. 脊柱外科杂志, 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. 张迪, 张文明, 周献伟, 等. 骨水泥螺钉联合多节段SchwabⅠ级截骨治疗陈旧性胸腰椎骨质疏松性骨折伴后凸畸形. 中国修复重建外科杂志, 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. 胡晓明, 于海洋, 郑国辉, 等. 陈旧性胸腰椎骨折后凸畸形术后近端交界性后凸发生的危险因素及生活质量研究. 实用骨科杂志, 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. 张鑫, 鲍虹达, 舒诗斌, 等. 颈2-股骨头中心位移和骶髂固定对成人脊柱畸形术后近端交界性后凸发生的影响研究. 中华医学杂志, 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. 崔西龙, 李贝贝, 张伟, 等. 俯卧位加压CT定位像在无神经症状胸腰段骨折畸形愈合继发后凸畸形矫形术中的意义. 颈腰痛杂志, 2021, 42(4): 451-454.
13. 张旭, 于海洋, 梁成民, 等. 俯卧位脊柱全长加压CT检查在骨质疏松性脊柱骨折伴后凸畸形治疗中的作用. 中国脊柱脊髓杂志, 2018, 28(6): 516-521.
14. 张子方, 郑国权, 薛超, 等. 成人脊柱畸形矫形术后早期躯体重心线(W-line)与近端交界区失败的相关性分析. 中国脊柱脊髓杂志, 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. 张坤坤, 于海洋, 梁成民, 等. 俯卧位脊柱全长加压CT检查在陈旧性骨质疏松性脊柱骨折伴中重度后凸畸形中的作用. 颈腰痛杂志, 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. 孙卓然, 姜帅, 邹达, 等. 国人青年人群坐-立位脊柱-骨盆矢状位序列变化研究. 中国脊柱脊髓杂志, 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, 陈少卿, 等. 基于铅垂线观察脊柱矢状面平衡的可行性. 脊柱外科杂志, 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

Abstract Full text Figures/Tables Video References Cited by

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