Prevention of PJF: Surgical Strategies to Reduce PJF. Robert Hart, MD Professor OHSU Orthopaedics Portland OR. Conflicts

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1 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 1

2 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 Topping Off Syndrome Proximal Junctional Fracture Fracture above all Pedicle Screw Construct (FPSC) Distinct from Proximal Junctional Kyphosis Proximal Junctional Acute Collapse 2

3 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: , 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, % Incidence of PJF 3

4 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,

5 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 5

6 Proximal Junctional Failure Severity Score PJFSS 1) Neurological Deficit 4) Change in Kyphosis/PLC Integrity None Radicular Pain Myelopathy/Weakness 2) Focal Pain None VAS 4 or Less VAS >= 5 3) Instrumentation Problem 0 pt 2 pt 4 pt 0 pt 1 pt 3 pt 0 10 Degrees 0 pt Degress 1 pt >20 Degrees 2 pt PLC Failure 2 pt 5) UIV/UIV+1 Fracture None Compression Fx Burst/Chance Fracture Translation 0 pt 1 pt. 2 pt. 3 pt. None Partial Fixation Loss Prominence Complete Fixation Loss 0 pt 1 pt 1 pt 2 pt 6) Level of UIV TL Junction Upper Thoracic 0 pt 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 6

7 Case Example 1: 70 YO Woman 1 Level TLIF 2 Year Follow-up Fracture T10 (UIV) Reciprocal Change 7

8 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 8

9 Case Example 73 YO Woman Degenerative S/P Laminectomy Tuning Correction Vertebral Augmentation PI = 65.0 T12-S1 LL =

10 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 10

11 4 Months Postop T3 PJF Pull Out of TP Hooks Second Revision Extended to C4 3 Years 10 Mos Post Index 11

12 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 12

13 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 13

14 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 14

15 Sagittal Realignment Mean Sagittal Vertical Axis improved from 128 mm positive imbalance to 38mm (Pelvic Incidence - Lumbar Lordosis) improved from 30.9 to /26 Fused to Sacro-Pelvis Pulmonary Complications 1 Pneumonia 1 Air Leak 1 Pulmonary Embolus (Fatality) PJF Results 5 PJF/3 PJF (19.2 and 11.5%) NO Revisions for PJF/PJK 15

16 Case Example 67 YO Woman BMI 42 Osteopenia Multiple Prior Surg Nearing 2 Year FU T4-Pelvis Fusion 2 Stage VCR L3 16

17 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 17

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