Distal Junctional Failure: A Feared Complication of Multilevel Posterior Spinal Fusions
Abstract
:1. Introduction
2. Methods
2.1. Study Design and Population
2.2. Definition of Distal Junctional Failure/Distal Junctional Kyphosis
2.3. Potential Risk Factors
- Older age (>65 years old);
- Osteoporosis;
- Long fusion (>4 levels);
- Fusion short of the first lordotic disc (FLD);
- Stopping the LIV at L5 or S1 without iliac fixation;
- Substance abuse/smoking;
- Hip osteoarthritis;
- Overcorrection of sagittal deformity greater than 50%;
- Sagittal imbalance.
2.4. Statistical Analysis
3. Results
3.1. Population and Operative Data (Table 1)
3.2. Radiographic Analysis (Table 2)
4. Discussion
Limitations of This Study
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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N | Age | Sex | Diagnosis/ Prior History | Index Surgery | Levels | IBD | Sagittal Imbalance (PI-LL Mismatch) | RF | Potential Cause | 1st Failure | 1st Revision | 2nd Failure | 2nd Revision | 3rd Failure | 3rd Revision |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 73 | F | T10 fracture and prior L2–L4 fusion | T10–L1 fusion, L2–L4 removal, L1–L2 decompression | 4 | No | N/A | Osteoporosis | L5 stop | L5 fracture | L5 kyphoplasty | _ | _ | _ | _ |
2 | 77 | M | Degenerative lumbar scoliosis | T10–L5 postero-lateral fusion | 8 | No | No | Osteoporosis | L5 stop | L5 screw pull-out | L4–L5 PSO, L4–L5 and L5–S1 TLIF, iliac bolts | S1 and iliac screw pull-out | Cementation around S1 and pelvic screws | _ | _ |
3 | 52 | F | L2–L3 degeneration; L3–L4 and L4–L5 DS | L2–L5 postero-lateral fusion | 4 | No | Yes | Smoker Alcohol | L5 stop | L5 pedicle screw pull-out, L4–L5 instability progression | T10-pelvis (S2AI screws); L5 PSO Schwab type 4 | Iliac screw fracture | Double iliac screws | Iliac screw fracture, L5–S1 non-union | L5–S1 ALIF, iliosacral screws, satellite right rod |
4 | 70 | F | Lumbar Kyphoscoliosis and L2–L3, L3–L4 and L4–L5 DS | T9–L5 fusion; L3 PSO Schwab type 4, L3–L4 TLIF | 9 | Yes | N/A | _ | L5 stop | Left L5 pedicle screw pull-out | L4–L5 and L5–S1 TLIF, iliac bolts | _ | _ | _ | _ |
5 | 76 | F | Lumbar kyphoscoliosis and L2–L3, L3–L4 and L4–L5 DS | T10–L5 fusion, L2–L3 decompression, TLIF L3L4 | 8 | Yes | N/A | Parkinson’s disease, Obesity | _ | L4–L5 stenosis | L4–L5 decompression | Bilateral pedicle screw pull-out/fracture | L5 PSO, L4–L5 TLIF, bilateral iliac fixation | _ | _ |
6 | 68 | F | Degenerative lumbar kyphoscoliosis | T10–S1 fusion, L3–L4 and L4–L5 decompression | 9 | No | No | Obesity | S1 stop, no iliac bolt | L5–S1 early kyphosis (DJK) | No revision yet | _ | _ | _ | _ |
7 | 49 | M | T10 fracture (T9–T11 fixation) post-traumatic kyphosis | T7–L1 fusion + PSO T9–T10 | 7 | No | Yes | _ | _ | AO A.1 fracture of L3 | L3 kyphoplasty | _ | _ | _ | _ |
8 | 80 | F | L1–L2, L2–L3 and L3–L4 stenosis | L1–L5 fusion | 5 | No | N/A | Obesity Diabetes | L5 stop | L4 screw pull-out; L4–L5 instability | L3–L4 TLIF, 2 level distal extension (S2) | _ | _ | _ | _ |
9 | 59 | M | Thoraco–lumbar kyphoscoliosis | T10–T11 dynamic stabilization, T11–S1 fusion, TLIF L2–L3, L3–L4 and L4–L5 | 8 | Yes | No | Parkinson’s disease | S1 stop, no iliac bolt | S1 screw pull-out + L5–S1 instability | L5–S1 ALIF (only strut graft) + iliac bolts | L5–S1 non-union | L5–S1 ALIF with cage + rod change | Right Iliac Screw Fracture | Screw substitution |
10 | 65 | F | Lumbar degenerative kyphoscoliosis | T10–L5,TLIF L4L5 | 8 | Yes | No | Osteoporosis | L5 stop | L5 fracture + L5–S1 stenosis | L5–S1 ALIF | ALIF L5 screw fracture + L5–S1 non-union | Not revised yet | _ | _ |
11 | 20 | M | Kyphoscoliosis (double major) Prader Willi | T2–L4 fusion | 15 | No | N/A | Obesity | L5 stop | L5 fracture | L4 PSO, iliac extension | _ | _ | _ | _ |
12 | 62 | F | L3–L4 and L4–L5 lumbar stenosis | L3–L5 decompression and posterolateral fusion | 3 | No | N/A | Osteoporosis Smoker | L5 stop | L5–S1 instability | T12-pelvis (iliosacral screws), L5–S1 TLIF | _ | _ | _ | _ |
13 | 64 | M | L3–L4 lumbar stenosis; L4–L5 DS | L3–L5 decompression and posterolateral fusion | 3 | No | Yes | _ | L5 stop | L2–L3 and L5–S1 stenosis | L2–L3 fusion, L5–S1 decompression | L5–S1 iatrogenic spondylolisthesis | L5–S1 fusion left iliac fixation | _ | _ |
14 | 64 | F | L2–L5 stenosis | L2–L5 decompression and posterolateral fusion | 4 | No | Yes | Obesity, Smoker, Parkinson’s disease | L5 stop | L5 fracture, T8–T9 disc herniation, L1–L2 stenosis | T8–T9 decompression, L4–L5 PSO + T2-pelvis fusion, L4–L5 TLIF | _ | _ | _ | _ |
15 | 70 | F | Multilevel lumbar stenosis | T12–S1 decompression and posterolateral fusion | 7 | No | Yes | Obesity, Smoker | Sagittal imbalance Flat back | Screw pull-out L5 and S1 | L5 PSO Schwab type 4,T10-pelvis fusion | _ | _ | _ | _ |
16 | 78 | M | Multilevel lumbar stenosis (L1–S1 fusion) | L1–L5 decompression and posterolateral fusion | 5 | No | N/A | Osteoporosis | _ | Proximal screw pull-out (PJF) | L4 PSO + T8-pelvis fusion, L5–S1 TLIF | Iliac screw fractures | Iliosacral screws, L4–L5 and L5–S1 ALIF | L1 non-union (intercalary junctional failure) | 5 Rod Construct |
17 | 69 | F | Multilevel lumbar DS | L3–S1 decompression | 4 | No | Yes | Parkinson’s disease | _ | L5–S1 compression | T11-pelvis fusion, L3–L4 and L4–L5 LLIF | Pelvic fixation pull-out | Iliosacral screws, L4–L5 and L5–S1 ALIF | _ | _ |
18 | 65 | F | Multilevel lumbar stenosis L2–L5 with prior L2–L5 decompression/Thoracolumbar kyphosis | T10-pelvis fusion, L3–L4, L4–L5, and L5–S1 TLIFs | 9 | Yes | N/A | Obesity | _ | Pelvic fixation pull-out | L4 PSO Schwab type 3, T8-pelvis fusion | Pelvic fixation pull-out | Iliosacral screws | _ | _ |
19 | 69 | M | Lumbar degenerative kyphoscoliosis | T10-pelvis fusion and L5–S1 TLIF | 9 | Yes | Yes | Osteoporosis | Gas in L2–L3, L3–L4, L4–L5 discs | Pelvic fixation pull-out | Pelvic revision with iliosacral screws |
Pre Op Index | Post Op Index | p | Pre Operative 2 | Post Operative 2 | p | Pre Operative 3 | Post Operative 3 | |
---|---|---|---|---|---|---|---|---|
SVA | 60.43 ± 55.24 | 37.64 ± 34.4 | 0.211 | 78.52± 64.57 | 41 ± 45.22 | 0.065 | 139.05 ± 20.53 | 126 ± 12.72 |
PI | 53.93 ± 19.9 | 53.14 ± 12.6 | 0.413 | 54.42 ± 22.16 | 52.94 ± 19.53 | 0.984 | 71.5 ± 23.33 | 68 ± 24.04 |
LL (L1S1) | 21 ± 28.1 | 32.62 ± 34 | 0.1 | 0.5 ± 34.86 | 15.3 ± 48.3 | 0.226 | 34.33 ± 36.67 | 62.5 ± 3.53 |
PI-LL | 30.79 ± 20.9 * | 9.81 ± 11.7 * | 0.013 | 31 ± 27.67 | 9.64 ± 18.04 | 0.0548 | 11.67 ± 11.71 | 5.5 ± 20.50 |
SS | 21.1 ± 15.05 | 23.1 ± 16.4 | 0.378 | 13.5 ± 17.09 * | 25.37 ± 16.13 * | 0.022 | 28.67 ± 19.50 | 54.5 ± 16.26 |
PT | 30 ± 14.2 | 24.4 ± 8.1 | 0.129 | 34.75 ± 17.17 * | 22.06 ± 14.52 * | 0.032 | 22 ± 19.67 | 13.05 ± 7.77 |
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Ghailane, S.; Bouloussa, H.; Fernandes Marques, M.; Castelain, J.-E.; Challier, V.; Campana, M.; Jacquemin, C.; Vital, J.-M.; Gille, O. Distal Junctional Failure: A Feared Complication of Multilevel Posterior Spinal Fusions. J. Clin. Med. 2024, 13, 4981. https://doi.org/10.3390/jcm13174981
Ghailane S, Bouloussa H, Fernandes Marques M, Castelain J-E, Challier V, Campana M, Jacquemin C, Vital J-M, Gille O. Distal Junctional Failure: A Feared Complication of Multilevel Posterior Spinal Fusions. Journal of Clinical Medicine. 2024; 13(17):4981. https://doi.org/10.3390/jcm13174981
Chicago/Turabian StyleGhailane, Soufiane, Houssam Bouloussa, Manuel Fernandes Marques, Jean-Etienne Castelain, Vincent Challier, Matthieu Campana, Clément Jacquemin, Jean-Marc Vital, and Olivier Gille. 2024. "Distal Junctional Failure: A Feared Complication of Multilevel Posterior Spinal Fusions" Journal of Clinical Medicine 13, no. 17: 4981. https://doi.org/10.3390/jcm13174981