Yusuke Hori, Akira Matsumura, Takashi Namikawa, Norihiro Isogai, Luiz Carlos Almeida da Silva, Burak Kaymaz, Petya K Yorgova, Peter G Gabos, Nicholas D Fletcher, Michael P Kelly, Harry L Shufflebarger, Peter O Newton, Burt Yaszay, Paul D Sponseller, Baron S Lonner, Amer F Samdani, Firoz Miyanji, Suken A Shah
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As LIV moves distally, a patient's motion, function, and chance of degeneration may all be negatively affected.</p><p><strong>Methods: </strong>This study included patients with Lenke 1/2 curves who underwent thoracic PSF (LIV≤L1); development of DJK (DJA≥10°) was evaluated 2 years postoperatively. Preoperative DJA was measured between LIV and LIV+1, consistent with postoperative measurements. Multiple logistic regression models identified risk factors for developing DJK. DeLong's test compared area under the curve (AUC) from different receiver operating characteristic curves to assess DJK predictive accuracy between models.</p><p><strong>Results: </strong>Of 1,034 patients, 86 (8%) developed DJK 2 years postoperatively. Identified risk factors included preoperative DJA, LIV at ≥SSV-2, an upper instrumented vertebra of ≥T2, lumbar modifiers B or C, and larger T5-12 kyphosis. Incorporating preoperative DJA and SSV-1 for LIV selection enhanced DJK prediction accuracy over solely considering SSV inclusion (AUC=0.81 vs. 0.72, P<0.001). Furthermore, a multivariate model with risk factors achieved the highest AUC (0.87). Patients with DJK experienced worsening of T10-L2 kyphosis and lumbar lordosis over time, without affecting the Scoliosis Research Society-22 quality of life score. Among those who developed DJK, five required an extension of fixation distally.</p><p><strong>Conclusion: </strong>To prevent DJK, PSF should end below preoperative kyphosis and no more proximal than SSV-1 in patients with thoracic adolescent idiopathic scoliosis, particularly for high-risk cases. DJK led to kyphotic regional thoracolumbar alignment at 2-year follow-up.</p><p><strong>Level of evidence: </strong>Level Ⅲ-retrospective comparative study.</p>","PeriodicalId":22193,"journal":{"name":"Spine","volume":" ","pages":""},"PeriodicalIF":2.6000,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Optimal Selection of Lower Instrumented Vertebra Can Minimize Distal Junctional Kyphosis After Posterior Spinal Fusion for Thoracic Adolescent Idiopathic Scoliosis.\",\"authors\":\"Yusuke Hori, Akira Matsumura, Takashi Namikawa, Norihiro Isogai, Luiz Carlos Almeida da Silva, Burak Kaymaz, Petya K Yorgova, Peter G Gabos, Nicholas D Fletcher, Michael P Kelly, Harry L Shufflebarger, Peter O Newton, Burt Yaszay, Paul D Sponseller, Baron S Lonner, Amer F Samdani, Firoz Miyanji, Suken A Shah\",\"doi\":\"10.1097/BRS.0000000000005336\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Study design: </strong>Retrospective cohort study of a prospectively collected multicenter database.</p><p><strong>Objective: </strong>To identify risk factors for developing distal junctional kyphosis (DJK) and elucidate optimal selection of the lowest instrumented vertebra (LIV) utilizing sagittal stable vertebra (SSV) and preoperative distal junctional angle (DJA) to prevent DJK.</p><p><strong>Summary of background data: </strong>While including the SSV may minimize DJK following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis, relying solely on the SSV criteria can necessitate more extensive fusion. As LIV moves distally, a patient's motion, function, and chance of degeneration may all be negatively affected.</p><p><strong>Methods: </strong>This study included patients with Lenke 1/2 curves who underwent thoracic PSF (LIV≤L1); development of DJK (DJA≥10°) was evaluated 2 years postoperatively. Preoperative DJA was measured between LIV and LIV+1, consistent with postoperative measurements. Multiple logistic regression models identified risk factors for developing DJK. DeLong's test compared area under the curve (AUC) from different receiver operating characteristic curves to assess DJK predictive accuracy between models.</p><p><strong>Results: </strong>Of 1,034 patients, 86 (8%) developed DJK 2 years postoperatively. Identified risk factors included preoperative DJA, LIV at ≥SSV-2, an upper instrumented vertebra of ≥T2, lumbar modifiers B or C, and larger T5-12 kyphosis. Incorporating preoperative DJA and SSV-1 for LIV selection enhanced DJK prediction accuracy over solely considering SSV inclusion (AUC=0.81 vs. 0.72, P<0.001). Furthermore, a multivariate model with risk factors achieved the highest AUC (0.87). Patients with DJK experienced worsening of T10-L2 kyphosis and lumbar lordosis over time, without affecting the Scoliosis Research Society-22 quality of life score. Among those who developed DJK, five required an extension of fixation distally.</p><p><strong>Conclusion: </strong>To prevent DJK, PSF should end below preoperative kyphosis and no more proximal than SSV-1 in patients with thoracic adolescent idiopathic scoliosis, particularly for high-risk cases. 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引用次数: 0
摘要
研究设计：前瞻性多中心数据库的回顾性队列研究。目的：探讨发生远端结缔组织后凸（DJK）的危险因素，并阐明利用矢状稳定椎体（SSV）和术前远端结缔组织角（DJA）来预防DJK的最低固定椎体（LIV）的最佳选择。背景资料总结：虽然包括SSV可以减少青少年特发性脊柱侧凸后路脊柱融合术（PSF）后的DJK，但仅依靠SSV标准可能需要更广泛的融合。当LIV向远端移动时，患者的运动、功能和变性的机会都可能受到负面影响。方法：本研究纳入Lenke 1/2曲线患者，行胸部PSF (LIV≤L1)；术后2年评估DJK （DJA≥10°）的发展情况。在LIV和LIV+1之间测量术前DJA，与术后测量结果一致。多重逻辑回归模型确定了DJK发病的危险因素。DeLong的试验比较了不同受者工作特征曲线的曲线下面积（AUC），以评估模型之间DJK预测的准确性。结果：1034例患者中，86例（8%）术后2年发生DJK。确定的危险因素包括术前DJA、LIV≥SSV-2、上固定椎体≥T2、腰椎修饰物B或C以及较大的T5-12后凸。结合术前DJA和SSV-1进行LIV选择比单独考虑SSV纳入提高了DJK预测的准确性（AUC=0.81 vs. 0.72）。结论：为了预防DJK，对于胸部青少年特发性脊柱侧凸患者，PSF应低于术前后凸，且不超过SSV-1的近端，特别是对于高危病例。在2年的随访中，DJK导致区域性胸腰椎对准后凸。证据等级：Ⅲ级——回顾性比较研究。
Optimal Selection of Lower Instrumented Vertebra Can Minimize Distal Junctional Kyphosis After Posterior Spinal Fusion for Thoracic Adolescent Idiopathic Scoliosis.
Study design: Retrospective cohort study of a prospectively collected multicenter database.
Objective: To identify risk factors for developing distal junctional kyphosis (DJK) and elucidate optimal selection of the lowest instrumented vertebra (LIV) utilizing sagittal stable vertebra (SSV) and preoperative distal junctional angle (DJA) to prevent DJK.
Summary of background data: While including the SSV may minimize DJK following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis, relying solely on the SSV criteria can necessitate more extensive fusion. As LIV moves distally, a patient's motion, function, and chance of degeneration may all be negatively affected.
Methods: This study included patients with Lenke 1/2 curves who underwent thoracic PSF (LIV≤L1); development of DJK (DJA≥10°) was evaluated 2 years postoperatively. Preoperative DJA was measured between LIV and LIV+1, consistent with postoperative measurements. Multiple logistic regression models identified risk factors for developing DJK. DeLong's test compared area under the curve (AUC) from different receiver operating characteristic curves to assess DJK predictive accuracy between models.
Results: Of 1,034 patients, 86 (8%) developed DJK 2 years postoperatively. Identified risk factors included preoperative DJA, LIV at ≥SSV-2, an upper instrumented vertebra of ≥T2, lumbar modifiers B or C, and larger T5-12 kyphosis. Incorporating preoperative DJA and SSV-1 for LIV selection enhanced DJK prediction accuracy over solely considering SSV inclusion (AUC=0.81 vs. 0.72, P<0.001). Furthermore, a multivariate model with risk factors achieved the highest AUC (0.87). Patients with DJK experienced worsening of T10-L2 kyphosis and lumbar lordosis over time, without affecting the Scoliosis Research Society-22 quality of life score. Among those who developed DJK, five required an extension of fixation distally.
Conclusion: To prevent DJK, PSF should end below preoperative kyphosis and no more proximal than SSV-1 in patients with thoracic adolescent idiopathic scoliosis, particularly for high-risk cases. DJK led to kyphotic regional thoracolumbar alignment at 2-year follow-up.
Level of evidence: Level Ⅲ-retrospective comparative study.
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Recognized internationally as the leading journal in its field, Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of Spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine. The Journal does not publish articles reporting material that has been reported at length elsewhere.
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