Floccari Lorena V, Su Alvin W, McIntosh Amy L, Rathjen Karl, Shaughnessy William J, Larson A Noelle
Department of Orthopedic Surgery, Mayo Clinic, Rochester MN.
Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas TX.
J Pediatr Orthop. 2019 Apr;39(4):202-208. doi: 10.1097/BPO.0000000000000898.
Adjacent segment pathology is a known complication after spinal fusion, but little has been reported on junctional failure. A series of adolescent patients presented with acute distal junctional failure (DJF). We sought to determine any common features of these patients to develop a prevention strategy.
A retrospective review was conducted of pediatric patients who developed DJF after instrumented spinal fusion performed at 2 institutions from 1999 to 2013. Patients with proximal junctional failure or junctional kyphosis without failure were excluded.
Fifteen subjects were identified with mean follow-up of 38 months. Distal failure occurred a mean of 60 days after index surgery, with history of minor trauma in 4 patients. Failures included 3-column Chance fracture (11) or instrumentation failure (4). Thirteen patients presented with back pain and/or acute kyphosis, whereas 2 asymptomatic patients presented with healed fractures. Two patients also developed new onset of severe lower extremity neurological deficit after fracture, which improved but never resolved after revision. A total of 13/15 subjects required revision surgery, typically within 1 week. Complications associated with revision surgery were encountered in 8 patients (62%). Major complications that required return to the operating room included 2 deep infections, 2 instrumentation failures, and dense lower extremity paralysis that improved after medial screw revision and decompression. At final follow-up, 10 patients are asymptomatic, 2 have persistent neurological deficit, 2 have chronic pain, and 1 has altered gait with gait aid requirement.
This study analyzes a heterogenous cohort of spinal fusion patients who developed DJF from 3-column Chance fracture or instrumentation failure. Revision surgery is typically required, but has a high complication rate and can result in severe neurological deficit, highlighting the morbidity of this complication. It is unclear whether level of the lowest instrumented vertebra contributes to DJF. Increased awareness of junctional failure in children may prompt additional studies to further characterize risk factors and preventative strategies.
Level IV-study-type case series.
相邻节段病变是脊柱融合术后已知的并发症，但关于交界区失败的报道较少。一系列青少年患者出现急性远端交界区失败（DJF）。我们试图确定这些患者的共同特征以制定预防策略。
对1999年至2013年在2家机构接受器械辅助脊柱融合术后发生DJF的儿科患者进行回顾性研究。排除近端交界区失败或交界区后凸但无失败的患者。
确定了15名受试者，平均随访38个月。远端失败平均发生在初次手术后60天，4例患者有轻微外伤史。失败包括三柱Chance骨折（11例）或内固定失败（4例）。13例患者出现背痛和/或急性后凸，而2例无症状患者出现骨折愈合。2例患者骨折后还出现新的严重下肢神经功能缺损，翻修后有所改善但未完全恢复。15例受试者中有13例需要翻修手术，通常在1周内进行。8例患者（62%）出现与翻修手术相关的并发症。需要返回手术室的主要并发症包括2例深部感染、2例内固定失败以及内侧螺钉翻修和减压后改善的严重下肢瘫痪。在最后随访时，10例患者无症状，2例有持续性神经功能缺损，2例有慢性疼痛，1例步态改变需要助行器。
本研究分析了一组因三柱Chance骨折或内固定失败而发生DJF的脊柱融合患者的异质性队列。通常需要翻修手术，但并发症发生率高，可导致严重神经功能缺损，突出了该并发症的发病率。尚不清楚最低固定椎体的节段是否与DJF有关。提高对儿童交界区失败的认识可能会促使更多研究进一步明确危险因素和预防策略。
IV级——研究类型为病例系列。
