Proximal Junctional Kyphosis in Surgically Treated Young Children

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Proximal Junctional Kyphosis in Surgically Treated Young Children With Scoliosis: Incidence, Risk Factors, and

Proximal Junctional Kyphosis in Surgically Treated Young Children With Scoliosis: Incidence, Risk Factors, and Management Bang-ping QIAN, Xu SUN, Xi CHEN, Yong QIU Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, China Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

PJK in children treated with GR surgery Ø 88 patients with EOS treated with

PJK in children treated with GR surgery Ø 88 patients with EOS treated with dual growing rods Ø PJK developed in 23 patients (26%) Ø The significant independent risk factors for PJK: Ø an LIV at or cranial to L 3, Ø a proximal thoracic scoliosis of 40° or more, Ø and a main thoracic kyphosis of 60° or more. Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

A total of 68 patients underwent VEPTR treatment at a single institution Four patients

A total of 68 patients underwent VEPTR treatment at a single institution Four patients developed PJK (6%). Patients with preoperative thoracic hyperkyphosis may be at higher risk. PJK can develop within the first year of VEPTR treatment. Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

PJK in children treated with fusion surgery # 9634 M 7 y # 6770

PJK in children treated with fusion surgery # 9634 M 7 y # 6770 F 6 y 6 m-Po-op CS, T 10 -L 2, T 12’ HV VCR 3 m-Po-op 6 m-post-op 14 m-post-op CS, PSF T 7 -L 1 Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Natural Course of PJK in AIS l Most of PJK was progressed within 3

Natural Course of PJK in AIS l Most of PJK was progressed within 3 months after surgery and did not progress significantly after 2 years postoperatively l The incidence of PJK at 7. 3 years postoperation was 26% (50 of 193 patients). l The average PJA increased 15. 2° until 2 years postoperatively and then increased 1. 7 °until final follow -up in the PJK group. Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Prevalence of PJK AIS Adults Lee 46% Kim 39% Kim 28% Mendoza. Lattes 35%

Prevalence of PJK AIS Adults Lee 46% Kim 39% Kim 28% Mendoza. Lattes 35% Hollenbeck 9. 2% Bridwell 27. 8% Helgeson 8. 1% (PS) Misuru -yagi 26% Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Objective To determine the incidence, risk factors, and behavior of proximal junctional kyphosis (PJK)

Objective To determine the incidence, risk factors, and behavior of proximal junctional kyphosis (PJK) in young children undergoing posterior instrumented spinal fusion. Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Material and Methods Inclusion criteria Age at surgery less than 10 yrs Diagnosed with

Material and Methods Inclusion criteria Age at surgery less than 10 yrs Diagnosed with congenital scoliosis Surgery: posterior fusion≥ 4 levels Follow-up>2 y UIV location: T 1 -T 11 Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Proximal junctional angle measurement PJA 20 ° Ø The proximal junction was defined as

Proximal junctional angle measurement PJA 20 ° Ø The proximal junction was defined as the caudal endplate of the UIV to the cephalad endplate of 2 proximal vertebrae. # 9634 M 7 y Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Results 61 consecutive patients Age Follow-up • From 2009 to 2011 in our institution

Results 61 consecutive patients Age Follow-up • From 2009 to 2011 in our institution • 5. 4 years (2 -10 years) • 2. 7 years (2 -4 years) Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Results Incidence of PJK 18. 0% 28. 21% 61 consecutive young children with scoliosis

Results Incidence of PJK 18. 0% 28. 21% 61 consecutive young children with scoliosis were included Overall incidence of PJK was 18. 0% (11/61) at follow-up 3 m-po-op: 10 PJK 3 -6 m: 11 PJK 2 y-po-op: 9 PJK Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Results Progression of PJA in PJK group 20. 6° 23. 1° 3 m-Post-op 2

Results Progression of PJA in PJK group 20. 6° 23. 1° 3 m-Post-op 2 y-post-op 6. 2° Pre-op Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Radiographic Findings of PJK Kyphotic deformity Bone implant interface failure 36° Bone failure Spine

Radiographic Findings of PJK Kyphotic deformity Bone implant interface failure 36° Bone failure Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

# 9094 M 6 y Bone fuilure of UIV 38° Spine Surgery, Drum Tower

# 9094 M 6 y Bone fuilure of UIV 38° Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

#6700 F 7 y Dislodgement of upmost screws 24° Spine Surgery, Drum Tower Hospital,

#6700 F 7 y Dislodgement of upmost screws 24° Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

No clinical symptoms #9094 M 6 y PJK #8535 M 9 y Non-PJK Spine

No clinical symptoms #9094 M 6 y PJK #8535 M 9 y Non-PJK Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Discussion Hyperkyphosis #8689 F 8 Y Po-op 75 ° PJA: 7 ° 2 y-Po-op

Discussion Hyperkyphosis #8689 F 8 Y Po-op 75 ° PJA: 7 ° 2 y-Po-op 17° PJA: 21 ° PJA: 27° Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

p Proximal instrumentation failure #7021 M 6 y Po-op Spine Surgery, Drum Tower Hospital,

p Proximal instrumentation failure #7021 M 6 y Po-op Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA 2 y-Po-op

p Un-matching of rod contour #6670 M 8 y 3 m-Po-op 9 m-Po-op Spine

p Un-matching of rod contour #6670 M 8 y 3 m-Po-op 9 m-Po-op Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Bracing for PJK #5746 M 6 y Po-op 3 m-Po-op Spine Surgery, Drum Tower

Bracing for PJK #5746 M 6 y Po-op 3 m-Po-op Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

9 m-Po-op Begin bracing 24 m-Po-op 36 m-Po-op 42 m-Po-op Spine Surgery, Drum Tower

9 m-Po-op Begin bracing 24 m-Po-op 36 m-Po-op 42 m-Po-op Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Occurrence of DJK after Bracing #8994 F 5 y Po-op 6 m-Po-op PJK 19°

Occurrence of DJK after Bracing #8994 F 5 y Po-op 6 m-Po-op PJK 19° Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

2 y+3 m-Po-op 6 m-Po-B 2 y-Po-op 3 m-Po-B PJK: 10° PJK: 16° DJK:

2 y+3 m-Po-op 6 m-Po-B 2 y-Po-op 3 m-Po-B PJK: 10° PJK: 16° DJK: 16° Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Conclusion Not a lower incidence of PJK in children with fusion surgery. PJK mainly

Conclusion Not a lower incidence of PJK in children with fusion surgery. PJK mainly occurred within 6 months postoperatively, and its risk factors included preoperative hyperkyphosis , proximal instrumentation failure, and un-matching of rod contour. Bracing served as a salvage option for PJK in young children. Spine Surgery, Drum Tower Hospital, Nanjing University, CHINA

Thank you for your attention! Spine Surgery, Drum Tower Hospital, Nanjing University, The Joint

Thank you for your attention! Spine Surgery, Drum Tower Hospital, Nanjing University, The Joint Scoliosis Research Center of the Chinese University of Hong. CHINA Kong & Nanjing