Junctional Kyphotic Deformity

[lorrie]

Hi Folks
Back to the hospital again today. The good news is that Geeve's back has not oozed any more and the bit that had gone funny is looking much better - flat and dry. we just have to keep an eye on that and go back straight away if it discharges any more.
The bad news is that she's developed a junctional kyphotic deformity which is why the ends of the rods are so prominent and causing some problems. apparently her spine is curving above the top of the fusion. if it gets any worse, it will be necessary either to shorten the rods a little at the top (with a bolt cutter, I'm told) or to extend the fusion and pull her spine back straight again. In the meantime we just keep watching, hope it doesn't worsen and go back next month.
Does anyone have any experience with this?

Lorrie

[LindaRacine]

Hi Lorrie...

I also have junctional kyphosis, although probably to a lesser degree than your child. It can be prevented by the surgeon choosing the proper levels for fusion. I don't mean to undermine the trust you have in this surgeon, but I've come to believe that the reason to pick the surgeon with the most experience is to assure that the proper levels are fused.

Best of luck with the additional surgery.

Regards,
Linda

[Mary Lou]

Lorrie,

My daughter also has Kyphosis above her fusion-about 27* at her six month check up. She is fused starting at the T3 level. Her doctor told us before surgery that there was a possibility of Kyphosis above the fusion. (I guess I should mention that she had surgery to correct both her Scoliosis and her Kyphosis) Has the doctor told you what the degree of her Kyphosis is? Has he said at what degree he would consider more surgery? Best of luck.

Mary Lou

[lorrie]

hi Folks
Thanks for info. Our surgeon is very experienced and reputed to be one of the best in the country. In spite of the problems we're having I have a great deal of confidence in him. We were warned some time ago that Genevieve was always going to be a high risk patient - the cerebral palsy complicates everything and it can be almost impossible to predict exactly how her body will react to any intervention - be it bracing or surgery or just growing.

We've not had any figure put on the kyphosis as yet. Coincidentally, Mary lou, Genevieve is also fused from T3.
Since I last posted, she has precipitated matters a bit - the fluid which had built up over the rods is now discharging and I'm currently waiting for the hospital to call and tell mewhen to bring her in today to have it looked at. I suspect we may need to do something sooner rather than later. Wish us luck!
Lorrie

[ProudParents]

Junctional kyphosis is not all that uncommon as evidenced by the 27% rate of PJK in the study below. It can occur above the fusion (Proximal or PJK) or below the fusion (Distal or DJK). I did a Dogpile search on both and got many hits. Our daughter is at risk for developing PJK because she matched many of the contributing factors mentioned in this study. Our surgeon took these factors into account and fused to T2, but that still doesn’t guarantee PJK won’t develop. The study:

Yong Jung Kim, MD Saint Louis MO (n)
Lawrence G Lenke, MD Saint Louis MO (a - Medtronic Sofamor Danek)
Keith H Bridwell, MD Saint Louis MO (a - Medtronic Sofamor Danek)
Junghoon Kim, MD Saint Louis MO (n)
Samuel Cho, MD Saint Louis MO (n)

The incidence of PJK was 27 percent. Thoracoplasty, larger number of fused vertebrae, thoracic hyperkyphosis and male correlated with PJK.
To determine the incidence of proximal junctional kyphosis (PJK) and analyze risk factors associated with PJK in adolescent idiopathic scoliosis (AIS) patients undergoing posterior only spinal fusion.
Radiographic data on 328 consecutive AIS patients with a minimum of 2 year follow-up treated with instrumented segmental posterior spinal fusion was collected. Radiographic measurements and SRS 24 outcome scores were analyzed. Abnormal PJK was defined by proximal junction sagittal Cobb angle between the lower end plate of the uppermost instrumented vertebra and the upper end plate of 2 supra-adjacent vertebrae at least 10 degrees greater than the preoperative measurement.
Incidence of PJK was 27% (89 patients) (39% male and 24% female, p=0.017). The number of fused vertebrae more than 12 vertebrae (vs 12 vertebrae or less, P=0.039), thoracoplasty (vs without, p=0.009), thoracic hyperkyphosis (p is less than 0.001) were attributed to PJK. The incidence of PJK according to the instrumentation types were 23% (44 among189) with hooks only, 30% (26 among 86) with hybrid construct (proximal hook and distal pedicle screw), and 36% (19 among 53) with pedicle screw instrumentation (Hook only vs Pedicle Screws, p=0.065). The SRS 24 outcome scores did not demonstrate any significant differences.
The incidence of PJK was 27%. Thoracoplasty, larger number of fused vertebrae, thoracic hyperkyphosis and male sex correlated significantly with PJK. The SRS 24 outcome scores did not demonstrate any significant differences.

[patif]

After reading this thread, I think I have PJK also. However my surgeon has never mentioned this to me. Will removing or shortening the rods help this?
I am 55 and had surgery & thoroplasty a little over a year ago. About three months after the initial surgery, I had revision surgery to fix the top of the rods b/c they had "unhooked" and were poking my back. The rods are very long and I can still feel them above my shoulder blades. Could the "long" rods have anything to do with the PJK?

Pat F

[LindaRacine]

Hi Pat...

I don't think so, however you still could have the problem. In my case, it feels like my head is too far forward, causing fatigue at the top of my spine.

Regards,
Linda

[Mary Lou]

Hmmm, ProudParents,

That study is very interesting. Jamie has a long fusion (T3-L2); she has thoracic Kyphosis (great corrections from surgery, however); she doesn't have any pedicle screws at all; she did not have a thoracoplasty. We can also feel the top of Jamie's rod. Jamie is 14 y.o. and only weighs about 91# and we were told before surgery because of her size, this could possibly happen. At her six month check up, everything was still in place, no loose hooks, no broken rods, etc.

Linda,

Jamie has never complained of her neck hurting, but like you, it looks like her head is too far front. At times, it almost looks like her head is coming out the front of her chest instead of from the top of her shoulders. Know what I mean?

Mary Lou

[lorrie]

Hi Folks
Just a quick update before I go back to the hospital. As I said, I was waiting for a call to tell me when to take Geeve to the hospital to have her oozy bit looked at.
Well, when we got there, they took one look and didn't let us come home. G was straight on antibiotics and confined to bed. The following Monday (21st) she was back in theatre having the area cleaned out, the rods trimmed ad re-fixed at the top. It seems that it is likely that the lingering infection (probably still there from before) had allowed the rods to loosen at the top.
We now have to throw antibiotics at it for about another month or six weeks and pray that there's no further recurrence.
Planning now is to try to keep the infection under control as long as possible to allow her back to fuse (if it's gonna) but that it's likely that the metalwork will have to come out sooner or later - we hope later.
If it has to come out in the near future then it's likely that she would subsequently need further fusion surgery and the insertion of new rods. Which doesn't even bear thinking about!
Genevieve was allowed up on Friday for the first time so we're hoping to get home early next week.
Thanks for all your thoughts andprayers.
Lorrie