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what is the chance of developing abnormal kyphosis after surgery?

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  • what is the chance of developing abnormal kyphosis after surgery?

    did any of you all experience an increase in kyphosis in the unfused portion of the upper back after scoliosis surgery? i am fused up to t5, and i'm afraid the unfused portion of my upper back will start hunching over, and that there won't be anything i can do about it.

    thanks.

  • #2
    Originally posted by sacket View Post
    did any of you all experience an increase in kyphosis in the unfused portion of the upper back after scoliosis surgery? i am fused up to t5, and i'm afraid the unfused portion of my upper back will start hunching over, and that there won't be anything i can do about it.

    thanks.
    Spine (Phila Pa 1976). 2010 Jan 15;35(2):219-26.

    Revision rates following primary adult spinal deformity surgery: six hundred forty-three consecutive patients followed-up to twenty-two years postoperative.
    Pichelmann MA, Lenke LG, Bridwell KH, Good CR, O'Leary PT, Sides BA.

    Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.

    Abstract
    STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the prevalence of and reasons for unanticipated revision surgery in an adult spinal deformity population treated at one institution. SUMMARY OF BACKGROUND DATA: No recent studies exist that analyze the rate or reason for unanticipated revision surgery for adult spinal deformity patients over a long period. METHODS: All patients presenting for primary instrumented spinal fusion with a diagnosis of adult deformity at a single institution from 1985 to 2008 were reviewed using a prospectively acquired database. All surgical patients with instrumented fusion of > or =5 levels using hooks, hybrid, or screw-only constructs were identified. Patient charts and radiographs were reviewed to provide information as to the indication for initial and any subsequent reoperation. A total of 643 patients underwent primary instrumented fusion for a diagnosis of adult idiopathic scoliosis (n = 432), de novo degenerative scoliosis (n = 104), adult kyphotic disease (n = 63), or neuromuscular scoliosis (n = 45). The mean age was 37.9 years (range, 18-84). Mean follow-up for the entire cohort was 4.7 years, and 8.2 years for the subset of the cohort requiring reoperation (range, 1 month-22.3 years). RESULTS: A total of 58 of 643 patients (9.0%) underwent at least one revision surgery and 15 of 643 (2.3%) had more than one revision (mean 1.3; range, 1-3). The mean time to the first revision was 4.0 years (range, 1 week-19.7 years). The most common reasons for revision were pseudarthrosis (24/643 = 3.7%; 24/58 = 41.4%), curve progression (13/643 = 2.0%; 13/58 = 20.7%), infection (9/643 = 1.4%; 9/58 = 15.5%), and painful/prominent implants (4/643 = 0.6%; 4/58 = 6.9%). Uncommon reasons consisted of adjacent segment degeneration (3), implant failure (3), neurologic deficit (1), and coronal imbalance (1). Revision rates over the follow-up period were: 0 to 2 years (26/58 = 44.8%), 2 to 5 years (17/58 = 29.3%), 5 to 10 years (7/58 = 12.1%), >10 years (8/58 = 13.8%). CONCLUSION: Repeat surgical intervention following definitive spinal instrumented fusion for primary adult deformity performed at a single institution demonstrated a relatively low rate of 9.0%. The most common reasons for revision were predictable and included pseudarthrosis, proximal or distal curve progression, and infection.

    PMID: 20038867 [PubMed - indexed for MEDLINE]
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

    Comment


    • #3
      Spine (Phila Pa 1976). 2009 Apr 15;34(8):832-9.

      Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
      Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

      Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.

      Abstract
      STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBJECTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.

      PMID: 19365253 [PubMed - indexed for MEDLINE]
      Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
      ---------------------------------------------------------------------------------------------------------------------------------------------------
      Surgery 2/10/93 A/P fusion T4-L3
      Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

      Comment


      • #4
        Those are great studies and I wish there were more such.
        How do you think their stats compare to those of the general population of patients (with age and surgical difficulty factored in)?

        I can't help thinking pts at those two facilities must fare much better than average - one of the main reasons I want to go to Lenke/Bridwell despite the considerable distance (and if I could afford it, I'd swing out West too!).

        I wish the HSS would publish such a longitudinal review.
        Not all diagnosed (still having tests and consults) but so far:
        Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
        main curve L Cobb 60, compensating T curve ~ 30
        Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

        Comment


        • #5
          Originally posted by Back-out View Post
          Those are great studies and I wish there were more such.
          How do you think their stats compare to those of the general population of patients (with age and surgical difficulty factored in)?

          I can't help thinking pts at those two facilities must fare much better than average - one of the main reasons I want to go to Lenke/Bridwell despite the considerable distance (and if I could afford it, I'd swing out West too!).

          I wish the HSS would publish such a longitudinal review.
          I don't know about WUSTL, but at UCSF the average age of all patients coming into the clinic is probably about 60-70 years. Both institutions do far more complicated cases than the standard deformity clinic.

          By the way, adjacent segment disease includes degeneration both above and below the fusion, so you can see that the incidence is relatively small. I suspect it is MUCH higher when the spine surgeon does a lot fewer surgeries (especially adult surgeries).
          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
          ---------------------------------------------------------------------------------------------------------------------------------------------------
          Surgery 2/10/93 A/P fusion T4-L3
          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

          Comment


          • #6
            Originally posted by LindaRacine View Post
            I don't know about WUSTL, but at UCSF the average age of all patients coming into the clinic is probably about 60-70 years. Both institutions do far more complicated cases than the standard deformity clinic.
            Just what I figured and why I thought it good to allow for that in interpreting their results.
            By the way, adjacent segment disease includes degeneration both above and below the fusion, so you can see that the incidence is relatively small. I suspect it is MUCH higher when the spine surgeon does a lot fewer surgeries (especially adult surgeries).
            I know. Girardi mentioned that to me too, but I figured if they go to the pelvis, there wouldn't be much to degenerate on the bottom - except, of course, for the possibility of a pelvic fracture.

            As for the top, I guess that risk exists, especially since I already start with degenerated disks everywhere (as per myelogram results), tho' thoracic is overall best. Cervical doesn't look all that great...I'm more concerned abt infection risk.

            Your "suspicion" is why I most seek a surgeon who does plenty of complex "adult" spines.

            I sure wish I could get to UCSF! Say, DO they take BCBS? And do they have any special housing arrangements making stay-overs cheaper than ordinary hotels for pts. and helpers?
            Not all diagnosed (still having tests and consults) but so far:
            Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
            main curve L Cobb 60, compensating T curve ~ 30
            Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

            Comment


            • #7
              Here's another one out of WUSTL that has quite a different outcome:

              Spine (Phila Pa 1976). 2008 Sep 15;33(20):2179-84.
              Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up.

              Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G.

              Washington University Medical Center, St. Louis, Missouri, USA.
              Abstract

              STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze time-dependent change of, prevalence of, and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity after long (> or =5 vertebrae) segmental posterior spinal instrumented fusion with a minimum 5-year postoperative follow-up. SUMMARY OF BACKGROUND DATA: No study has focused on time-dependent long-term proximal junctional change in adult spinal deformity after segmental posterior spinal instrumented fusion with minimum 5-year follow-up. METHODS: Clinical and radiographic data of 161 (140 women/21 men) adult spinal deformity patients with minimum 5-year follow-up (average 7.8 years, range 5-19.8 years) treated with long posterior spinal instrumentation and fusion were analyzed. Radiographic measurements included sagittal Cobb angle at the proximal junction on preoperative, 8-weeks postoperation, 2-year postoperation, and ultimate follow-up (> or =5 years). Postoperative SRS outcome scores were also evaluated. RESULTS: The prevalence of PJK at 7.8 years postoperation was 39% (62/161 patients). The PJK group (n = 62) demonstrated a significant increase in proximal junctional angle at 8 weeks (59%), between 2 years postoperation and ultimate postoperation (35%), and in thoracic kyphosis (T5-T12) at ultimate follow-up (P = 0.001). However, the sagittal vertical axis change at ultimate follow-up did not correlate with PJK (P = 0.53). Older age at surgery >55 years (vs. < or =55 years) and combined anterior and posterior spinal fusion (vs. posterior only) demonstrated significantly higher PJK prevalence (P = 0.001, 0.041, respectively). The SRS outcome scores did not demonstrate significant differences with the exception of the self-image domain when PJK exceeded 20 degrees. CONCLUSION: The prevalence of PJK at 7.8 years postoperation was 39%. PJK progressed significantly within 8 weeks postoperation (59%) and between 2 years postoperation and ultimate follow-up (35%). Older age at surgery (>55 years) and combined anterior and posterior spinal fusion were identified as risk factors for developing PJK. The SRS outcome instrument was not adversely affected by PJK, except when PJK exceeded 20 degrees.

              PMID: 18794759 [PubMed - indexed for MEDLINE]

              Please note, by the way, that so far the abstracts I've posted are looking at revision surgeries. The actual incidence of adjacent segment disease is probably much higher, as a lot of people with PJK never have it fixed. (I have PJK and probably won't have it fixed.)
              Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
              ---------------------------------------------------------------------------------------------------------------------------------------------------
              Surgery 2/10/93 A/P fusion T4-L3
              Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

              Comment


              • #8
                Here's one that is not a revision surgery paper.

                Spine (Phila Pa 1976). 2005 Jul 15;30(14):1643-9.
                Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis.

                Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd.

                Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
                Abstract

                STUDY DESIGN: To analyze patient outcomes and risk factors associated with proximal junctional kyphosis (PJK) in adults undergoing long posterior spinal fusion. OBJECTIVES: To determine the incidence of PJK and its effect on patient outcomes and to identify any risk factors associated with developing PJK. SUMMARY OF BACKGROUND DATA: The incidence of PJK and its affect on outcomes in adult deformity patients is unknown. No study has concentrated on outcomes of patients with PJK. Risk factors for developing PJK are unknown. METHODS: Radiographic data on 81 consecutive adult deformity patients with minimum 2-year follow-up (average 5.3 years, range 2-16 years) treated with long instrumented segmental posterior spinal fusion was collected. Preoperative diagnosis was adult scoliosis, sagittal imbalance or both. Radiographic measurements analyzed included the sagittal Cobb angle at the proximal junction on preoperative, early postoperative, and final follow-up standing long cassette radiographs. Additional measurements used for analysis included the C7-Sacrum sagittal plumb and the T5-T12 sagittal Cobb. Postoperative SRS-24 scores were available on 73 patients. RESULTS: Incidence of PJK as defined was 26%. Patients with PJK did not have lower outcomes scores. PJK did not produce a more positive sagittal C7 plumb. PJK was more common at T3 in the upper thoracic spine. CONCLUSIONS: Incidence of proximal junctional kyphosis was high, but SRS-24 scores were not significantly affected in patients with PJK. The sagittal C7 plumb was not significantly more positive in PJK patients. No patient, radiographic, or instrumentation variables were identified as risk factors for developing PJK.

                PMID: 16025035 [PubMed - indexed for MEDLINE]
                Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                ---------------------------------------------------------------------------------------------------------------------------------------------------
                Surgery 2/10/93 A/P fusion T4-L3
                Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                Comment


                • #9
                  Yes, the UCSF surgeons take BC/BS, as do the vast majority of the country's surgeons. If you have an HMO plan, however, I doubt you'd get referred to San Francisco.

                  As far as I know, the deals on San Francisco hotels are still going to be a lot more $ than what you're being quoted elsewhere.

                  --Linda
                  Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                  ---------------------------------------------------------------------------------------------------------------------------------------------------
                  Surgery 2/10/93 A/P fusion T4-L3
                  Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                  Comment


                  • #10
                    So, to summarize the above, it looks like the overall odds are ~ 40% at study's endpoint, for developing PJK OR thoracic kyphosis, and extrapolating, much higher for pts > 55 yrs, undergoing P/A approach. Also, that this starts developing almost immediately post-surgery and steadily worsens.

                    Now I know why 2/3 surgeons wanted to fuse me from T4 down instead of T10 even though, above T10 "everything is fine" (per third surgeon). I wonder if the higher fusion would prevent this occurring in me and/or if targeted PT could reduce the risk.

                    I was especially interested in the sentence before you started bolding:
                    The SRS outcome scores did not demonstrate significant differences with the exception of the self-image domain when PJK exceeded 20 degrees.

                    In other words, patients developing this problem were nonetheless deemed to be doing fine EXCEPT FOR SELF-IMAGE!
                    Not all diagnosed (still having tests and consults) but so far:
                    Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                    main curve L Cobb 60, compensating T curve ~ 30
                    Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                    Comment


                    • #11
                      Brilliant question, sacket!
                      Not all diagnosed (still having tests and consults) but so far:
                      Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                      main curve L Cobb 60, compensating T curve ~ 30
                      Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                      Comment


                      • #12
                        i asked Dr L. whether i was likely to need revision surgery, since he will start my fusion at T11...he said he didnt think so...and he wouldnt fuse more of my back based on the chance something might happen...
                        i liked his answer...

                        jess

                        Comment


                        • #13
                          Kyphosis 5 Years Out

                          Well, I recently posted on the revision portion of this site about my worsening kyphosis after 5 years. I was 54 at the time of my surgery, and was fused A/P from T-5 to L-4. I am now wondering if it wouldn't be wise just to fuse all the way up, but I guess that's not how it's done, and perhaps with good reason. Why anticipate trouble before it actually occurs? I just saw my surgeon for the first time in over 2 1/2 years a couple of weeks ago. Unfortunately, the x-ray folks weren't there, so I had to get those later and will see Doc again on July 2nd. To my untrained eye, my kyphotic curve looks very much worse than those years ago. I feel it everyday as I try to stand and have to fight my neck to keep my head erect. I suspected from comments on this site that I might also have saggital imbalance, but Doc doesn't think so. I would be delighted if I only have to deal with the "upper" surgery and only one means of entry, as opposed to the alternative. Thanks, Linda, for the informative studies, though it's amazing I could muddle through all the "shop talk." I was wondering if the "blame" if there is any, needs to be placed upon the surgeon, or if the nature of the beast is such that there are so many variables in a surgery this complex that one has to shoot one's best shot and hope for the best. My husband and I suspect the latter. At this point, I just want to be able to walk upright comfortably again, and I'm willing to endure whatever it takes to accomplish that, as I am unable to accept that my current physiology is what I will be stuck with forever.
                          I am so grateful for this site and everyone herein!!!!
                          Singing the Blues
                          Female 1951
                          A/P Surgery Oct 13th & 17th '05, from T7-L5, 46 degree curve reduced to 19 degrees. Rib hump almost gone, but I have flatback. Thought it was "normal" and I would improve over time. I developed kyphosis above the surgical area. Had surgery with Dr Menmuir in Reno, Nv on October 13, 2010.
                          Today I am still plagued with flatback, and I'm considering ALIF surgery.

                          Comment


                          • #14
                            Linda, hoping you see this...

                            I posted my last reply to you. in a cross-post while you were getting ready to put up the second Washington U review of PJK and I confess I'm COMPLETELY confused.

                            First, my comment only applies to the first study.

                            Second, you say that all your (first three) links including the first PJK link were of a revision cohort.

                            I must have finally burnt out on all this, but I have tried to reread both of them, and I don't see anywhere it says the first one is a population of revision pts.

                            Also (and this is more embarrassing) I can't really tell them apart meaningfully . . I'll try to reread them when less is going on here, but meanwhile, I wonder if you can supply any simple pointers as to what their different purposes and conclusions were.

                            Flummoxed utterly

                            Amanda
                            Not all diagnosed (still having tests and consults) but so far:
                            Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                            main curve L Cobb 60, compensating T curve ~ 30
                            Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                            Comment


                            • #15
                              hi Sharon
                              i'm so sorry to hear of the problems you are having with the newly developed kyphosis...i already am "particularly hypokyphotic in thoracic spine", but have "good overall balance" per my surgeon...he wants to fuse T11-pelvis, and says he wont assume future problems in upper portion not being fused, because there is no guarantee it will happen...
                              i really dont think it is the fault of the surgeon when it happens...and i trust the guy enough to go with his decision, if/when i have it done...
                              that said, it is rotten that it happened to you...am wondering if you have any interest in seeking help from a pain management doctor, or whether you are considering revision surgery only...?

                              hope you feel better
                              jess

                              Comment

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