Raj Aditya, Lee Chong-Suh, Park Jin-Sung, Kang Byeong-Jik, Shin Tae Soo, Park Se-Jun
J Neurosurg Spine. 2022 Mar 25;37(3):402-409. doi: 10.3171/2022.2.SPINE211387. Print 2022 Sep 1.
Score on the proximal junctional kyphosis severity scale (PJKSS) has been validated to show good correlations with likelihood of revision surgery for proximal junctional failure (PJF) after surgical treatment of adult spinal deformity (ASD). However, if the patient has progressive neurological deterioration, revision surgery should be considered regardless of severity based on PJKSS score. This study aimed to revalidate the correlation of PJKSS score with likelihood of revision surgery in patients with PJF but without neurological deficit. In addition, the authors provide the cutoff score on PJKSS that indicates need for revision surgery.
A retrospective study was performed. Among 360 patients who underwent fusion of more than 4 segments including the sacrum, 83 patients who developed PJF without acute neurological deficit were included. Thirty patients underwent revision surgery (R group) and 53 patients did not undergo revision surgery (NR group). All components of PJKSS and variables other than those included in PJKSS were compared between groups. The cutoff score on PJKSS that indicated need for revision surgery was calculated with receiver operating characteristic curve analysis. Multivariate analysis with logistic regression was performed to identify which variables were most predictive of revision surgery.
The mean patient age at the time of index surgery was 69.4 years, and the mean fusion length was 6.1 segments. All components of PJKSS, such as focal pain, instrumentation problem, change in kyphosis, fracture at the uppermost instrumented vertebra (UIV)/UIV+1, and level of UIV, were significantly different between groups. The average total PJKSS score was significantly greater in the R group than in the NR group (6.0 vs 3.9, p < 0.001). The calculated cutoff score was 4.5, with 70% sensitivity and specificity. There were no significant between-group differences in patient, surgical, and radiographic factors (other than the PJKSS components). Three factors were significantly associated with revision surgery on multivariate analysis: instrumentation problem (OR 8.160, p = 0.004), change in kyphosis (OR 4.809, p = 0.026), and UIV/UIV+1 fracture (OR 6.462, p = 0.002).
PJKSS score positively predicted need for revision surgery in patients with PJF who were neurologically intact. The calculated cutoff score on PJKSS that indicated need for revision surgery was 4.5, with 70% sensitivity and specificity. The factor most responsible for revision surgery was bony failure with > 20° focal kyphotic deformity. Therefore, early revision surgery should be considered for these patients even in the absence of neurological deficit.
近端交界性后凸严重程度量表（PJKSS）评分已被证实与成人脊柱畸形（ASD）手术治疗后近端交界性失败（PJF）翻修手术的可能性具有良好的相关性。然而，如果患者出现进行性神经功能恶化，无论基于PJKSS评分的严重程度如何，都应考虑进行翻修手术。本研究旨在重新验证PJKSS评分与无神经功能缺损的PJF患者翻修手术可能性之间的相关性。此外，作者提供了PJKSS上表明需要进行翻修手术的临界值。
进行了一项回顾性研究。在360例行包括骶骨在内的4节段以上融合手术的患者中，纳入83例发生PJF且无急性神经功能缺损的患者。30例患者接受了翻修手术（R组），53例患者未接受翻修手术（NR组）。比较两组之间PJKSS的所有组成部分以及PJKSS未包括的变量。通过受试者工作特征曲线分析计算出表明需要进行翻修手术的PJKSS临界值。进行多因素逻辑回归分析以确定哪些变量最能预测翻修手术。
初次手术时患者的平均年龄为69.4岁，平均融合节段数为6.1个。PJKSS的所有组成部分，如局部疼痛、内固定问题、后凸变化、最上端固定椎体（UIV）/UIV+1骨折以及UIV水平，在两组之间均有显著差异。R组的平均PJKSS总分显著高于NR组（6.0对3.9，p<0.001）。计算出的临界值为4.5，灵敏度和特异度均为70%。患者、手术和影像学因素（除PJKSS组成部分外）在两组之间无显著差异。多因素分析显示，三个因素与翻修手术显著相关：内固定问题（OR 8.160，p=0.004）、后凸变化（OR 4.809，p=0.026）和UIV/UIV+1骨折（OR 6.462，p=0.002）。
PJKSS评分能积极预测无神经功能缺损的PJF患者是否需要进行翻修手术。计算出的表明需要进行翻修手术的PJKSS临界值为4.5，灵敏度和特异度均为70%。导致翻修手术的最主要因素是伴有>20°局部后凸畸形的骨失败。因此，即使这些患者没有神经功能缺损，也应考虑早期进行翻修手术。
