Hart Robert, McCarthy Ian, Oʼbrien Michael, Bess Shay, Line Brett, Adjei Oheneba Boachie, Burton Doug, Gupta Munish, Ames Christopher, Deviren Vedat, Kebaish Khaled, Shaffrey Christopher, Wood Kirkham, Hostin Richard
*Oregon Health Sciences University, Portland, OR †Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX; and ‡Southern Methodist University, Dallas, TX; §Baylor Scoliosis Center, Plano, TX ¶Rocky Mountain Scoliosis and Spine, Denver, CO ‖Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY **Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS ††Department of Orthopedic Surgery, University of California Davis, Sacramento, CA ‡‡Department of Neurological Surgery, University of California San Francisco, San Francisco, CA §§Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA; ¶¶Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD ‖‖Department of Neurological Surgery, University of Virginia, Charlottesville, VA ***Massachusetts General Hospital, Boston, MA; and †††Denver, CO.
Spine (Phila Pa 1976). 2013 Sep 1;38(19):E1223-7. doi: 10.1097/BRS.0b013e31829fedde.
Multicenter, retrospective, consecutive case series.
This study aims to identify demographic and radiographical characteristics that influence the decision to perform revision surgery among patients with proximal junctional failure (PJF).
Revision rates after PJF remain relatively high, yet the decision criteria for performing revision surgical procedures are not uniform and vary by surgeon. A better understanding of the factors that impact the decision to perform revision surgery is important in order to improve efficiency of surgical treatment of adult spinal deformity.
A cohort of 57 patients with PJF was identified retrospectively from 1218 consecutive patients with adult spinal deformity. PJF was identified on the basis of 10° postoperative increase in kyphosis between upper instrumented vertebra (UIV) and UIV +2, along with 1 or more of the following: fracture of the vertebral body of UIV or UIV +1, posterior osseoligamentous disruption, or pullout of instrumentation at the UIV. Univariate statistical analysis was performed using t tests and Fisher exact tests. Multivariate analysis was performed using logistic regression.
Twenty-seven (47.4%) patients underwent revision surgery within 6 months of the index operation. Regression results revealed that patients with combined posterior/anterior approaches at index were significantly more likely to undergo revision (P = 0.001) as were patients with more extreme proximal junctional kyphosis angulation (P = 0.034). Patients sustaining trauma were also significantly more likely to undergo revision (P = 0.019). Variables approaching but not reaching significance as predictors of revision included female sex (P = 0.066) and higher sagittal vertical axis (SVA) (P = 0.090).
The decision to perform revision surgery is complicated and varies by surgeon. Factors that seem to influence this decision include traumatic etiology of PJF, severity of proximal junctional kyphosis angulation, higher SVA, and female sex. Factors that were expected to influence revision but had no statistical effect included soft tissue versus bony mode of failure, age, levels fused, and upper thoracic versus thoracolumbar proximal junction.
多中心、回顾性、连续病例系列研究。
本研究旨在确定影响近端交界性失败（PJF）患者翻修手术决策的人口统计学和影像学特征。
PJF后的翻修率仍然相对较高，但进行翻修手术的决策标准并不统一，且因外科医生而异。更好地了解影响翻修手术决策的因素对于提高成人脊柱畸形手术治疗的效率很重要。
从1218例连续的成人脊柱畸形患者中回顾性确定了57例PJF患者队列。PJF的确定基于术后上固定椎（UIV）与UIV +2之间后凸增加10°，以及以下1项或多项：UIV或UIV +1椎体骨折、后部骨韧带破坏或UIV处内固定拔出。使用t检验和Fisher精确检验进行单变量统计分析。使用逻辑回归进行多变量分析。
27例（47.4%）患者在初次手术后6个月内接受了翻修手术。回归结果显示，初次手术采用后路/前路联合入路的患者进行翻修的可能性显著更高（P = 0.001），近端交界性后凸角度更极端的患者也是如此（P = 0.034）。遭受创伤的患者进行翻修的可能性也显著更高（P = 0.019）。接近但未达到作为翻修预测指标显著性的变量包括女性（P = 0.066）和更高的矢状垂直轴（SVA）（P = 0.090）。
进行翻修手术的决策很复杂，且因外科医生而异。似乎影响这一决策的因素包括PJF的创伤性病因、近端交界性后凸角度的严重程度、更高的SVA和女性。预期会影响翻修但无统计学效应的因素包括软组织与骨组织的失败模式、年龄、融合节段、上胸椎与胸腰段近端交界。
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