Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques

Author:

Tretiakov Peter S.12,Lafage Renaud3,Smith Justin S.4,Line Breton G.5,Diebo Bassel G.6,Daniels Alan H.6,Gum Jeffrey7,Protopsaltis Themistocles1,Hamilton D. Kojo8,Soroceanu Alex8,Scheer Justin K.9,Eastlack Robert K.10,Mundis Gregory10,Nunley Pierce D.11,Klineberg Eric O.12,Kebaish Khaled13,Lewis Stephen14,Lenke Lawrence15,Hostin Richard16,Gupta Munish C.17,Ames Christopher P.9,Hart Robert A.18,Burton Douglas19,Shaffrey Christopher I.20,Schwab Frank3,Bess Shay5,Kim Han Jo21,Lafage Virginie3,Passias Peter G.12

Affiliation:

1. Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York;

2. Department of Orthopaedic Surgery, New York Spine Institute, New York, New York;

3. Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York;

4. Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;

5. Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;

6. Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island;

7. Norton Leatherman Spine Center, Louisville, Kentucky;

8. Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;

9. Department of Neurological Surgery, University of California, San Francisco, California;

10. Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California;

11. Spine Institute of Louisiana, Shreveport, Louisiana;

12. Department of Orthopaedic Surgery, University of California, Davis, California;

13. Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland;

14. Division of Orthopaedic Surgery, University of Toronto, Ontario, Canada;

15. Department of Orthopaedic Surgery, Columbia University, New York, New York;

16. Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas;

17. Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri;

18. Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington;

19. Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

20. Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and

21. Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York

Abstract

OBJECTIVE The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF). METHODS Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05. RESULTS Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit. CONCLUSIONS PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.

Publisher

Journal of Neurosurgery Publishing Group (JNSPG)

Subject

General Medicine

Reference37 articles.

1. Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development;Lau D,2014

2. Proximal junctional kyphosis and failure-diagnosis, prevention, and treatment;Nguyen NLM,2016

3. Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery;Hyun SJ,2017

4. Proximal junctional kyphosis;Kim HJ,2016

5. Surgical, radiographic, and patient-related risk factors for proximal junctional kyphosis: a meta-analysis;Kim JS,2019

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