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Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery

Jichao Ye Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China;

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Sachin Gupta Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;

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Ali S. Farooqi Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;

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Tsung-Cheng Yin Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan;

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Alex Soroceanu University of Calgary Spine Program, University of Calgary, Alberta, Canada;

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Frank J. Schwab Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;

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Virginie Lafage Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;

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Michael P. Kelly Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri;

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Khaled Kebaish Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland;

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Richard Hostin Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas;

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Jeffrey L. Gum Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky;

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贾斯汀·史密斯 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;

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Christopher I. Shaffrey Departments of Neurological Surgery and Orthopedic Surgery, Division of Spine Surgery, Duke University, Durham, North Carolina;

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Justin K. Scheer Department of Neurological Surgery, University of California, San Francisco, California;

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Themistocles S. Protopsaltis Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;

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Peter G. Passias Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;

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Eric O. Klineberg Department of Orthopaedic Surgery, University of California Davis, Sacramento, California;

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Han Jo Kim Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;

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Robert A. Hart Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington; and

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D. Kojo Hamilton Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

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Christopher P. Ames Department of Neurological Surgery, University of California, San Francisco, California;

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Munish C. Gupta Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri;

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MD , on behalf of the International Spine Study Group
Publication Date:
09 Jun 2023
Page Range:
1–9
Volume/Issue:
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DOI link:
https://doi.org/10.3171/2023.4.SPINE23209
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OBJECTIVE

Multiple rods are utilized in adult spinal deformity (ASD) surgery to increase construct stiffness. However, the impact of multiple rods on proximal junctional kyphosis (PJK) is not well established. This study aimed to investigate the impact of multiple rods on PJK incidence in ASD patients.

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ASD patients from a prospective multicenter database with a minimum follow-up of 1 year were retrospectively reviewed. Clinical and radiographic data were collected preoperatively, at 6 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, and at every subsequent year postoperatively. PJK was defined as a kyphotic increase of > 10° in the Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 as compared with preoperative values. Demographic data, radiographic parameters, and PJK incidence were compared between the multirod and dual-rod patient cohorts. PJK-free survival analysis was performed using Cox regression to control for demographic characteristics, comorbidities, level of fusion, and radiographic parameters.

RESULTS

Overall, 307/1300 (23.62%) cases utilized multiple rods. Cases with multiple rods were more likely to be revisions (68.4% vs 46.5%, p < 0.001), to be posterior only (80.7% vs 61.5%, p < 0.001), involve more levels of fusion (mean 11.73 vs 10.60, p < 0.001), and include 3-column osteotomy (42.9% vs 17.1%, p < 0.001). Patients with multiple rods also had greater preoperative pelvic retroversion (mean pelvic tilt 27.95° vs 23.58°, p < 0.001), greater thoracolumbar junction kyphosis (−15.9° vs −11.9°, p = 0.001), and more severe sagittal malalignment (C7–S1 sagittal vertical axis 99.76 mm vs 62.23 mm, p < 0.001), all of which corrected postoperatively. Patients with multiple rods had similar incidence rates of PJK (58.6% vs 58.1%) and revision surgery (13.0% vs 17.7%). The PJK-free survival analysis demonstrated equivalent PJK-free survival durations among the patients with multiple rods (HR 0.889, 95% CI 0.745–1.062, p = 0.195) after controlling for demographic and radiographic parameters. Further stratification based on implant metal type demonstrated noninferior PJK incidence rates with multiple rods in the titanium (57.1% vs 54.6%, p = 0.858), cobalt chrome (60.5% vs 58.7%, p = 0.646), and stainless steel (20% vs 63.7%, p = 0.008) cohorts.

CONCLUSIONS

Multirod constructs for ASD are most frequently utilized in revision, long-level reconstructions with 3-column osteotomy. The use of multiple rods in ASD surgery does not result in an increased incidence of PJK and is not affected by rod metal type.

ABBREVIATIONS

ASD = adult spinal deformity ; BMI = body mass index ; GT = global tilt ; LL = lumbar lordosis ; PI = pelvic incidence ; PI-LL = PI minus LL ; PJK = proximal junctional kyphosis ; PSO = pedicle subtraction osteotomy ; PT = pelvic tilt ; SS = sacral slope ; SVA = sagittal vertical axis ; UIV = upper instrumented vertebra ; VCR = vertebral column resection .
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Contributor Notes

CorrespondenceMunish C. Gupta: Washington University in St. Louis, MO.munishgupta@wustl.edu.

INCLUDE WHEN CITINGPublished online June 9, 2023; DOI: 10.3171/2023.4.SPINE23209.

Disclosures施瓦布博士报告咨询和专利费from Zimmer Biomet and MSD; consulting fees from Mainstay Medical; nonfinancial support for serving on the executive committee of the International Spine Study Group (ISSG); and stock from VFT Solutions and SeaSpine outside the submitted work. Dr. Lafage reported grants from the ISSG paid to an institution during the conduct of the study; consulting fees from Alphatec and Globus Medical; royalties from NuVasive; personal fees from Johnson & Johnson for lectures; personal fees from Stryker for lectures; executive committee membership of the ISSG; and committee membership of Scoliosis Research Society (SRS) outside the submitted work. Dr. Kelly reported personal fees from Wolters Kluwer and nonfinancial support from AO Spine outside the submitted work. Dr. Gum reported consulting and royalty fees from NuVasive and Acuity; reported consulting fees from Stryker, Mazor, Expanding Innovations, and DePuy; reported consulting fees and stock from FYR Medical; reported consulting fees, royalties, and patents from Medtronic; reported travel funds from the Fischer Owen Fund; reported honoraria from Baxter, Broadwater, NASS, Pacira Pharmaceuticals, and MiMedx; reported employment with Norton Healthcare; is a speaker for KyANA; serves on the medical/scientific board of the National Spine Health Foundation; serves as a journal reviewer for Global Spine Journal, Spine Deformity, and The Spine Journal; and reported stock from Cingulate Therapeutics outside the submitted work; and receives research funding paid to an institution from Pfizer, Texas Scottish Rites Hospital, Alan L. & Jacqueline B. Stuart Spine Research, Cerapedics, SRS, Biom’Up, Empirical Spine, National Spine Health Foundation, Stryker, and Medtronic. Dr. Smith reported grants from DePuy Synthes/ISSGF during the conduct of the study; personal fees from Cerapedics, Carlsmed, SeaSpine, ZimVie, NuVasive, and DePuy Synthes; grants from AO Spine; and personal stock in Alphatec and NuVasive outside the submitted work. Dr. Shaffrey reported grants from the ISSG Foundation paid to Duke University during the conduct of the study; and personal fees from NuVasive, Medtronic, SI Bone, and Proprio outside the submitted work. Dr. Protopsaltis reported personal fees from Globus Medical, Medtronic, NuVasive, and Stryker outside the submitted work; and a patent for Altus with royalties paid. Dr. Passias reported grants from Medtronic and Cerapedics; work on the design team of Globus; and consulting fees from Royal Biologics outside the submitted work. Dr. Klineberg reported consulting fees from DePuy Synthes, Stryker, Medtronic, SeaSpine, SI Bone, and Agnovos; stock from MMI and Relatable; fellowship grants from AO Spine; serves as the chair elect/fellowship chair of IMAST; and serves as chair elect of AO Spine outside the submitted work. Dr. Kim reported grants from ISSGF; personal fees from Zimmer Biomet, K2M/Stryker, Acuity Surgical, NuVasive, Vivex Biologics, and Aspen Medical; and grants from AO Spine outside the submitted work. Dr. Hart reported personal fees from Globus and SeaSpine outside the submitted work. Dr. Ames reported royalties from Stryker, K2M, Medicrea, Biomet Zimmer Spine, DePuy Synthes, NuVasive, and Next Orthosurgical; consulting fees from DePuy Synthes, Carlsmed, Medtronic, Medicrea, K2M, and Agada Medical; research fees from Titan Spine, DePuy Synthes, and ISSG; personal fees for serving on the editorial board of Operative Neurosurgery; grant funding from SRS; personal fees for serving on the executive committee of ISSG; personal fees for serving as director of Global Spinal Analytics; and personal fees for serving as the chair of the SRS Safety and Value Committee. Dr. M. Gupta reported royalties from Innomed; stock from J&J; royalties and consulting fees from DePuy and Globus; nonfinancial support from DePuy for travel to meetings; nonfinancial support from the SRS for serving on the board of directors and travel to meetings; nonfinancial support from Zimmer for travel for training; consulting fees from Medtronic; nonfinancial support from Medtronic and Globus for travel to meetings; and honoraria from LSU and Wright State for grand rounds outside the submitted work.
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