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Thread: Problems above the fusion after surgery

  1. #1
    Join Date
    Aug 2009

    Problems above the fusion after surgery

    Because my son has such a high curve, I've been paying attention to the occurrence of problems above the fusion after surgery. With older hardware, most of the problems after surgery were below the fusion. With the newer hardware, surgeons are seeing more problems above the fusion.

    There was an interesting article on this topic. (Which, of course, I can't find). But here's a recent article from Lenke about the occurrence of PJK after surgery.

    STUDY DESIGN.: Retrospective comparative study. OBJECTIVE.: We aimed to examine the difference in clinical outcomes in proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA.: To date, PJK has been primarily a radiographical finding. Inferior outcomes associated with PJK have not been reported. We performed an analysis of PJK in adult deformity patients to identify risk factors and to evaluate clinical outcomes. METHODS.: A total of 364 patients at a single institution from 2002 to 2007 with adult scoliosis, with an average 3.5 years' follow-up were analyzed. Inclusion criteria were age more than 18 years and fusion greater than 5 levels from any thoracic upper instrumented vertebrae to any lower instrumented vertebrae. Cobb measurements in the coronal and sagittal plane in addition to measurements of the PJK angle at postoperative time points were performed. Clinical assessment was performed using Scoliosis Research Society (SRS) scores and the Oswestry Disability Index. RESULTS.: The prevalence of PJK was 39.5% (144/364). The average age in the non-PJK group (n-PJK) was 48.9 versus 53.3 in the PJK group (PJK), and, specifically, age more than 60 years posed a higher prevalence. The prevalence of osteoporosis was 9.8% versus 20.4% in the n-PJK versus PJK groups, respectively. Sex, body mass index, revision surgery, and smoking status were not different between groups. Pain was prevalent in 0.9% versus 29.4% in n-PJK versus PJK, which resulted in lower composite SRS Pain scores (mean change +1.2 vs. +0.8), despite no differences seen in other SRS domains, total SRS score, or Oswestry Disability Index. On multivariate analysis, the presence of pain of the upper back was highly predictive of PJK (odds ratio, 12.5, 95% confidence interval, 2.5-63.2).Radiographically, no differences were seen between groups. However, increasing distance of the upper instrumented vertebrae to C7 plumb line had a higher prevalence of PJK. Instrumentation type, surgical approach, and crosslink use were not different between groups. CONCLUSION.: PJK results in worse clinical outcomes measured by the SRS Pain subscore. Our regression model suggests that pain in the upper back has a strong predictive value for PJK.Level of Evidence: 3.

  2. #2
    Join Date
    Aug 2009
    Here's a little about recommended follow up for patients seen to have PJK after surgery:

    ". On the basis of this result,
    we suggest that it is important to follow all patients who
    have PJK for at least 5-year postoperative time period. Two
    years of follow-up is not sufficient. Seventy percent of the
    PJ angle is progressed within the first 2 years postoperation, but it can be anticipated that approximately 30% of
    the PJ angle will be increased between 2 years and final

  3. #3
    Join Date
    Feb 2013
    Tampa, FL
    I worry about everything as we are facing my son's surgery and had read this article about PJK. Therefore, was listening to hear if any of our consults mentioned the risk of it, NONE. I didn't bring it up because it seemed like surgeons didn't really like hearing that I was online reading all this information! I doubt I'd avoid surgery over the fear so what is the point....

    In re-reading the article I can deduce he is not likely to have PJK since: his curve isn't high (T55), short fusion (T4-T12/L1), and he has no pain.

    So that is all good right?
    Mom to son with new straight spine 8/15/2013 T16, L16
    Pre op T65, L?
    diagnosed 2/21/13 T55, L42

  4. #4
    Join Date
    Aug 2009
    I think the key reassuring thing is the first thing they say - "To date, PJK has been primarily a radiographical finding." I believe that means that patients aren't coming in complaining about it after surgery - it's just something that they see when they take the after-surgery xrays. So, for most of these patients, it doesn't go on to be a problem. Only 30% of those where they see the PJK on the xray complain about pain.

    We have had a few people on the forum develop PJK after surgery, and a handful of those have needed further surgery to extend the fusion. It's a bigger deal, in my son's case, because his fusion would end right below his neck, so there's not really anywhere to continue the fusion other than going into the neck.

    Every single one of these articles lists a different possible cause, and I have no idea why. The smartest thing I've heard anyone say, and I don't actually know that it's right, it just made the most sense to me, was when Linda Racine said she thought the issue was that the surgeon hadn't fused to the right vertebrae and so had left a little bit of the curve still at the top.

    My son hasn't had spinal surgery, but he did have surgery on his jaw. I swear I read every single article listing every single problem, and he's had nary a one

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