Proximal junctional kyphosis (PJK) is a complication of surgical management for adult spinal deformity (ASD) with a multifactorial etiology. Many risk factors are controversial, and their relative importance is not fully understood. The authors aimed to elucidate the association between bone mineral density (BMD) and PJK.
开云体育世界杯赔率
A systematic literature search was performed using PubMed and Web of Science keywords of "Proximal Junctional Kyphosis [MeSH] OR Proximal Junctional Failure [MeSH]" AND "Bone Mineral Density [MeSH] OR Hounsfield Units [MeSH] OR DEXA [MeSH]" set to the date range of January 2002 to July 2022. Studies required a minimum of 10 patients and 12 months of follow-up. Articles were included if they were in the English language and presented a primary retrospective cohort that included a comparison of patients with and without PJK, as well as a radiographic biomarker for BMD, such as Hounsfield units (HU) or T-score.
RESULTS
A total of 18 unique studies with 2185 patients who underwent ASD surgery were identified. Of these, 537 patients (24.6%) developed PJK. Eight studies provided T-scores that were amenable to comparison, which found that patients who developed PJK were found to have lower BMD T-scores by a mean of −0.69 (95% CI −0.88 to −0.50; I2= 63.9%, p < 0.001). The HU at the UIV among patients with the PJK group (n = 101) compared with the non-PJK group (n = 156) was found to be significantly lower (mean difference −32.35, 95% CI −46.05 to −18.65; I2= 28.7%, p < 0.001).
结论
This meta-analysis suggests that low preoperative BMD as measured by T-score and a diagnosis of osteoporosis were associated with higher postoperative PJK. Additionally, lower HU on CT at the UIV were found to be significant risk factors for postoperative PJK as well. These findings suggest that more attention to preoperative BMD is a risk factor for PJK among ASD patients is warranted.
ABBREVIATIONS
ASD = adult spinal deformity;BMD = bone mineral density;DEXA = dual-energy x-ray absorptiometry;HU = Hounsfield units;MD = mean difference;PJF = proximal junctional failure;PJK = proximal junctional kyphosis;ROC = receiver operating characteristic;UIV = upper instrumented vertebra;YAM = young adult mean.
SebaalyA,SylvestreC,El QuehtaniY,et al.Incidence and risk factors for proximal junctional kyphosis: results of a multicentric study of adult scoliosis.Clin Spine Surg.2018;3.1(3.):E178–E183.
Sebaaly
A
,
Sylvestre
C
,
El Quehtani
Y
,
Incidence and risk factors for proximal junctional kyphosis: results of a multicentric study of adult scoliosis
.Clin Spine Surg
.
2018
;
3.1
(
3.
):
E178
–
E183
.
29596215)| false
SegretoFA,PassiasPG,LafageR,et al.Incidence of acute, progressive, and delayed proximal junctional kyphosis over an 8-year period in adult spinal deformity patients.Oper Neurosurg (Hagerstown).2020;18(1):75–82.
GlattesRC,BridwellKH,LenkeLG,KimYJ,RinellaA,EdwardsCII.Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis.Spine (Phila Pa 1976).2005;3.0(14):1643–1649.
HartRA,McCarthyI,AmesCP,ShaffreyCI,HamiltonDK,HostinR.Proximal junctional kyphosis and proximal junctional failure.Neurosurg Clin N Am.2013;24(2):213–218.
KimJS,PhanK,CheungZB,et al.Surgical, radiographic, and patient-related risk factors for proximal junctional kyphosis: a meta-analysis.Global Spine J.2019;9(1):3.2–40.
NichollsFH,BaeJ,TheologisAA,et al.Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients.Spine (Phila Pa 1976).2017;42(22):1693–1698.
Nicholls
FH
,
Bae
J
,
Theologis
AA
,
Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients
.Spine (Phila Pa 1976)
.
2017
;
42
(
22
):
1693
–
1698
.
28441308)| false
HostinR,McCarthyI,O'BrienM,et al.Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity.Spine (Phila Pa 1976).2013;3.8(12):1008–1015.
刘易斯SJ,AbbasH,ChuaS,et al.Upper instrumented vertebral fractures in long lumbar fusions: what are the associated risk factors?Spine (Phila Pa 1976).2012;3.7(16):1407–1414.
刘易斯
SJ
,
Abbas
H
,
Chua
S
,
Upper instrumented vertebral fractures in long lumbar fusions: what are the associated risk factors?Spine (Phila Pa 1976)
.
2012
;
3.7
(
16
):
1407
–
1414
.
22366970)| false
YagiM,AkilahKB,Boachie-AdjeiO.Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis.Spine (Phila Pa 1976).2011;3.6(1):E60–E68.
YagiM,FujitaN,TsujiO,et al.Low bone-mineral density is a significant risk for proximal junctional failure after surgical correction of adult spinal deformity: a propensity score-matched analysis.Spine (Phila Pa 1976).2018;43(7):485–491.
Yagi
M
,
Fujita
N
,
Tsuji
O
,
Low bone-mineral density is a significant risk for proximal junctional failure after surgical correction of adult spinal deformity: a propensity score-matched analysis
.Spine (Phila Pa 1976)
.
2018
;
43
(
7
):
485
–
491
.
28767638)| false
YagiM,KingAB,Boachie-AdjeiO.Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up.Spine (Phila Pa 1976).2012;3.7(17):1479–1489.
Yagi
M
,
King
AB
,
Boachie-Adjei
O
.
Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up
.Spine (Phila Pa 1976)
.
2012
;
3.7
(
17
):
1479
–
1489
.
22357097)| false
CarlsonBC,RobinsonWA,WandermanNR,et al.A review and clinical perspective of the impact of osteoporosis on the spine.Geriatr Orthop Surg Rehabil.2019;10:2151459319861591.
Carlson
BC
,
Robinson
WA
,
Wanderman
NR
,
A review and clinical perspective of the impact of osteoporosis on the spine
.Geriatr Orthop Surg Rehabil
.
2019
;
10
:
2151459319861591
.
3.1360592)| false
UeiH,TokuhashiY,MasedaM,et al.Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study.J Orthop Surg Res.2018;13(1):252.
Uei
H
,
Tokuhashi
Y
,
Maseda
M
,
Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study
.J Orthop Surg Res
.
2018
;
13
(
1
):
252
.)| false
DuanPG,MummaneniPV,RiveraJ,et al.The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up.Neurosurg Focus.2020;49(2):E7.
Duan
PG
,
Mummaneni
PV
,
Rivera
J
,
The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up
.Neurosurg Focus
.
2020
;
49
(
2
):
E7
.
3.2738804)| false
Egger
M
,
Davey Smith
G
,
Schneider
M
,
Minder
C
.
Bias in meta-analysis detected by a simple, graphical test
.BMJ
.
1997
;
3.15
(
7109
):
629
–
634
.
9310563)| false
HillsJM,WeisenthalBM,WannerJP,et al.A patient-specific approach to alignment and proximal junctional kyphosis risk assessment in adult spinal deformity surgery: development and validation of a predictive tool.Clin Spine Surg.2022;3.5(6):256–263.
HyunSJ,KimYJ,RhimSC.Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area.Spine J.2016;16(9):1095–1101.
Kurra
S
,
Farhadi
HF
,
Metkar
U
,
CT based bone mineral density as a predictor of proximal junctional fractures
.N Am Spine Soc J
.
2022
;
11
:
100130
.
3.5783005)| false
LeeKY,LeeJH,KangKC,ShinWJ,ImSK,ChoSJ.Preliminary report on the flexible rod technique for prevention of proximal junctional kyphosis following long-segment fusion to the sacrum in adult spinal deformity.J Neurosurg Spine.2019;3.1(5):703–710.
Lee
KY
,
Lee
JH
,
Kang
KC
,
Shin
WJ
,
Im
SK
,
Cho
SJ
.
Preliminary report on the flexible rod technique for prevention of proximal junctional kyphosis following long-segment fusion to the sacrum in adult spinal deformity
.J Neurosurg Spine
.
2019
;
3.1
(
5
):
703
–
710
.)| false
MikulaAL,LakomkinN,PenningtonZ,et al.Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine.J Neurosurg Spine.2022;3.7(5):694–702.
Mikula
AL
,
Lakomkin
N
,
Pennington
Z
,
Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine
.J Neurosurg Spine
.
2022
;
3.7
(
5
):
694
–
702
.)| false
MikulaAL,FogelsonJL,LakomkinN,et al.Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction.Oper Neurosurg (Hagerstown).2021;21(4):270–275.
Mikula
AL
,
Fogelson
JL
,
Lakomkin
N
,
Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction
.Oper Neurosurg (Hagerstown)
.
2021
;
21
(
4
):
270
–
275
.
3.4171907)| false
TamaiK,TeraiH,SuzukiA,et al.Risk factors for proximal junctional fracture following fusion surgery for osteoporotic vertebral collapse with delayed neurological deficits: a retrospective cohort study of 403 patients.Spine Surg Relat Res.2019;3.(2):171–177.
Tamai
K
,
Terai
H
,
Suzuki
A
,
Risk factors for proximal junctional fracture following fusion surgery for osteoporotic vertebral collapse with delayed neurological deficits: a retrospective cohort study of 403 patients
.Spine Surg Relat Res
.
2019
;
3.
(
2
):
171
–
177
.
3.1435571)| false
WangH,MaL,YangD,et al.Incidence and risk factors for the progression of proximal junctional kyphosis in degenerative lumbar scoliosis following long instrumented posterior spinal fusion.Medicine (Baltimore).2016;95(3.2):e4443.
Wang
H
,
Ma
L
,
Yang
D
,
Incidence and risk factors for the progression of proximal junctional kyphosis in degenerative lumbar scoliosis following long instrumented posterior spinal fusion
.Medicine (Baltimore)
.
2016
;
95
(
3.2
):
e4443
.
27512860)| false
WangH,DingW,MaL,ZhangL,YangD.Prevention of proximal junctional kyphosis: are polyaxial pedicle screws superior to monoaxial pedicle screws at the upper instrumented vertebrae?World Neurosurg.2017;101:405–415.
Wang
H
,
Ding
W
,
Ma
L
,
Zhang
L
,
Yang
D
.
Prevention of proximal junctional kyphosis: are polyaxial pedicle screws superior to monoaxial pedicle screws at the upper instrumented vertebrae?World Neurosurg
.
2017
;
101
:
405
–
415
.
28216210)| false
WangQ,WangC,ZhangX,et al.Correlation of vertebral trabecular attenuation in Hounsfield units and the upper instrumented vertebra with proximal junctional failure after surgical treatment of degenerative lumbar disease.J Neurosurg Spine.2021;3.4(3.):456–463.
Wang
Q
,
Wang
C
,
Zhang
X
,
Correlation of vertebral trabecular attenuation in Hounsfield units and the upper instrumented vertebra with proximal junctional failure after surgical treatment of degenerative lumbar disease
.J Neurosurg Spine
.
2021
;
3.4
(
3.
):
456
–
463
.)| false
YagiM,FujitaN,OkadaE,et al.Fine-tuning the predictive model for proximal junctional failure in surgically treated patients with adult spinal deformity.Spine (Phila Pa 1976).2018;43(11):767–773.
Yagi
M
,
Fujita
N
,
Okada
E
,
Fine-tuning the predictive model for proximal junctional failure in surgically treated patients with adult spinal deformity
.Spine (Phila Pa 1976)
.
2018
;
43
(
11
):
767
–
773
.
28902106)| false
YaoYC,ElyseeJ,LafageR,et al.Preoperative Hounsfield units at the planned upper instrumented vertebrae may predict proximal junctional kyphosis in adult spinal deformity.Spine (Phila Pa 1976).2021;46(3.):E174–E180.
YuanL,ZengY,ChenZ,LiW,ZhangX,MaiS.Degenerative lumbar scoliosis patients with proximal junctional kyphosis have lower muscularity, fatty degeneration at the lumbar area.Eur Spine J.2021;3.0(5):1133–1143.
Yuan
L
,
Zeng
Y
,
Chen
Z
,
Li
W
,
Zhang
X
,
Mai
S
.
Degenerative lumbar scoliosis patients with proximal junctional kyphosis have lower muscularity, fatty degeneration at the lumbar area
.Eur Spine J
.
2021
;
3.0
(
5
):
1133
–
1143
.
3.3.210198)| false
BridwellKH,LenkeLG,ChoSK,et al.Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle.开云体育app官方网站下载入口.2013;72(6):899–906.
KimHJ,BridwellKH,LenkeLG,et al.Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections.Spine (Phila Pa 1976).2014;3.9(9):E576–E580.
KimYJ,BridwellKH,LenkeLG,GlattesCR,RhimS,ChehG.Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up.Spine (Phila Pa 1976).2008;3.3.(20):2179–2184.
ParkSJ,LeeCS,ChungSS,LeeJY,KangSS,ParkSH.Different risk factors of proximal junctional kyphosis and proximal junctional failure following long instrumented fusion to the sacrum for adult spinal deformity: survivorship analysis of 160 patients.开云体育app官方网站下载入口.2017;80(2):279–286.
Park
SJ
,
Lee
CS
,
Chung
SS
,
Lee
JY
,
Kang
SS
,
Park
SH
.
Different risk factors of proximal junctional kyphosis and proximal junctional failure following long instrumented fusion to the sacrum for adult spinal deformity: survivorship analysis of 160 patients
.开云体育app官方网站下载入口
.
2017
;
80
(
2
):
279
–
286
.)| false
HaririAF,AlmatrafiMN,ZamkaAB,et al.起关系感情n body mass index and T-scores of bone mineral density in the hip and spine regions among older adults with diabetes: a retrospective review.J Obes.2019;2019:9827403.
Hariri
AF
,
Almatrafi
MN
,
Zamka
AB
,
起关系感情n body mass index and T-scores of bone mineral density in the hip and spine regions among older adults with diabetes: a retrospective review
.J Obes
.
2019
;
2019
:
9827403
.
3.1179127)| false
LloydJT,AlleyDE,HawkesWG,HochbergMC,WaldsteinSR,OrwigDL.Body mass index is positively associated with bone mineral density in US older adults.Arch Osteoporos.2014;9:175.
Lloyd
JT
,
Alley
DE
,
Hawkes
WG
,
Hochberg
MC
,
Waldstein
SR
,
Orwig
DL
.
Body mass index is positively associated with bone mineral density in US older adults
.Arch Osteoporos
.
2014
;
9
:
175
.
24664472)| false
MaruoK,HaY,InoueS,et al.Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity.Spine (Phila Pa 1976).2013;3.8(23):E1469–E1476.
Maruo
K
,
Ha
Y
,
Inoue
S
,
Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity
.Spine (Phila Pa 1976)
.
2013
;
3.8
(
23
):
E1469
–
E1476
.)| false
MikulaAL,PufferRC,JeorJDS,et al.Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes.J Neurosurg Spine.2020;3.2(1):50–55.
Mikula
AL
,
Puffer
RC
,
Jeor
JDS
,
Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes
.J Neurosurg Spine
.
2020
;
3.2
(
1
):
50
–
55
.)| false
FlaniganPM,MikulaAL,PetersPA,et al.Regional improvements in lumbosacropelvic Hounsfield units following teriparatide treatment.Neurosurg Focus.2020;49(2):E11.
YagiM,OhneH,KonomiT,et al.Teriparatide improves volumetric bone mineral density and fine bone structure in the UIV+1 vertebra, and reduces bone failure type PJK after surgery for adult spinal deformity.Osteoporos Int.2016;27(12):3.495–3.502.
Yagi
M
,
Ohne
H
,
Konomi
T
,
Teriparatide improves volumetric bone mineral density and fine bone structure in the UIV+1 vertebra, and reduces bone failure type PJK after surgery for adult spinal deformity
.Osteoporos Int
.
2016
;
27
(
12
):
3.495
–
3.502
.
27341809)| false
ChoiMK,KimSM,LimJK.Diagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT.Acta Neurochir (Wien).2016;158(7):1421–1427.
Choi
MK
,
Kim
SM
,
Lim
JK
.
Diagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT
.Acta Neurochir (Wien)
.
2016
;
158
(
7
):
1421
–
1427
.
27177734)| false
BatawilN,SabiqS.Hounsfield unit for the diagnosis of bone mineral density disease: a proof of concept study.Radiography.2016;22(2):e93–e98.
Batawil
N
,
Sabiq
S
.
Hounsfield unit for the diagnosis of bone mineral density disease: a proof of concept study
.Radiography
.
2016
;
22
(
2
):
e93
–
e98
.)| false
ZaidiQ,DanisaOA,ChengW.Measurement techniques and utility of Hounsfield unit values for assessment of bone quality prior to spinal instrumentation: a review of current literature.Spine (Phila Pa 1976).2019;44(4):E239–E244.
Zaidi
Q
,
Danisa
OA
,
Cheng
W
.
Measurement techniques and utility of Hounsfield unit values for assessment of bone quality prior to spinal instrumentation: a review of current literature
.Spine (Phila Pa 1976)
.
2019
;
44
(
4
):
E239
–
E244
.
3.0063528)| false
Garg
MK
,
Kharb
S
.
双能x线吸收仪:pitfalls in measurement and interpretation of bone mineral density
.Indian J Endocrinol Metab
.
2013
;
17
(
2
):
203
–
210
.
23776890)| false
Schreiber
JJ
,
Anderson
PA
,
Hsu
WK
.
Use of computed tomography for assessing bone mineral density
.Neurosurg Focus
.
2014
;
3.7
(
1
):
E4
.
24981903)| false
LeeS,ChungCK,OhSH,ParkSB.Correlation between bone mineral density measured by dual-energy x-ray absorptiometry and Hounsfield units measured by diagnostic CT in lumbar spine.J Korean Neurosurg Soc.2013;54(5):3.84–3.89.
Lee
S
,
Chung
CK
,
Oh
SH
,
Park
SB
.
Correlation between bone mineral density measured by dual-energy x-ray absorptiometry and Hounsfield units measured by diagnostic CT in lumbar spine
.J Korean Neurosurg Soc
.
2013
;
54
(
5
):
3.84
–
3.89
.
24379944)| false
Hocaoglu
E
,
Inci
E
,
Vural
M
.
Could computed tomography Hounsfield unit values of lumbar vertebrae detect osteoporosis?Curr Med Imaging
.
2021
;
17
(
8
):
988
–
995
.
3.3.438545)| false
KohanEM,NemaniVM,HershmanS,KangDG,KellyMP.Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity.Neurosurg Focus.2017;43(6):E4.
Kohan
EM
,
Nemani
VM
,
Hershman
S
,
Kang
DG
,
Kelly
MP
.
Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity
.Neurosurg Focus
.
2017
;
43
(
6
):
E4
.)| false
XuF,ZouD,LiW,et al.Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery.Neurosurg Focus.2020;49(2):E10.
Xu
F
,
Zou
D
,
Li
W
,
Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery
.Neurosurg Focus
.
2020
;
49
(
2
):
E10
.
32738800)| false
