Osteoporosis is a Risk Factor for Proximal Junctional Failure Following Long Spinal Fusion for Adult Spinal Deformity

Main Article Content

Sarthak Mohanty, MD Anmol Gupta, MD, MBA Harold Fogel, MD Daniel Tobert, MD Stuart Hershman, MD

Abstract

Background: Bone health has emerged as a critical modifiable risk factor for complications following adult spinal deformity correction. Among these complications, mechanical issues and proximal junctional kyphosis/failure remain particularly challenging, affecting up to 61% and 44% of patients, respectively. We hypothesized that osteoporotic patients undergoing deformity correction experience higher rates of instrumentation failure and proximal junctional kyphosis/failure.


Purpose: To evaluate and compare the complication profiles of osteoporotic and non-osteoporotic patients undergoing long thoracolumbar fusion for adult spinal deformity.


Study Design: Retrospective comparative study


Patient Sample: adult spinal deformity patients who underwent long thoracolumbar spinal fusion (>7 levels) at two large academic medical centers between 2010 and 2019.


Outcome Measures: The primary outcome was all-cause revision surgery. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis/failure rates, infection rates, and time to complication occurrence.


Methods: This retrospective, multicenter study analyzed deformity patients undergoing long-segment instrumentation (≥7 levels) with a minimum two-year follow-up. Exclusion criteria included spinal deformity secondary to tumor, infection, trauma, or neuromuscular disorders. Preoperative osteoporosis status was determined using dual-energy X-ray absorptiometry (DXA) T-scores at the hip and femoral neck. The complication profiles of osteoporotic and non-osteoporotic deformity patients were compared using Chi-squared or Fisher’s exact tests for categorical variables and two-tailed t-tests for continuous variables.


Results: Among 399 adult spinal deformity patients, 131 (32.8%) were osteoporotic. Osteoporotic patients were significantly older than their non-osteoporotic counterparts [66.43 (SD: 8.9) vs. 63.51 (SD: 8.9), P = 0.0018]. The overall complication rate was significantly higher in osteoporotic patients compared to non-osteoporotic patients [40.5% (n = 53) vs. 28.0% (n = 75), P = 0.0122]. Incidences of PJK [35.1% (n = 46) vs. 21.6% (n = 58), P = 0.0040] and PJF [19.8% (n = 26) vs. 6.7% (n = 18), P = 0.0001] were also higher in the osteoporotic group, while rates of construct failure/pseudarthrosis [11.5% vs. 15.7%, P = 0.2578] and infection [4.6% vs. 3.7%, P = 0.6849] showed no significant differences. Time to pseudarthrosis (8.1 vs. 8.3 months, P = 0.4582), infection (4.7 vs. 1.5 months, P = 0.0773), PJF (9.3 vs. 10.1 months, P = 0.7300), and overall time to first complication (8.4 vs. 7.6 months, P = 0.5119) were similar between the groups.


Conclusions: Osteoporotic patients have increased risk of proximal junctional kyphosis and failure compared to non-osteoporotic patients, highlighting the need for preoperative osteoporosis surveillance, optimization, and postoperative monitoring to mitigate complications.

Keywords: adult spinal deformity; scoliosis; osteoporosis; surgical complications; fusions; kyphosis; construct failure; revision

Article Details

How to Cite
MOHANTY, Sarthak et al. Osteoporosis is a Risk Factor for Proximal Junctional Failure Following Long Spinal Fusion for Adult Spinal Deformity. Medical Research Archives, [S.l.], v. 13, n. 1, jan. 2025. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/6199>. Date accessed: 10 feb. 2025. doi: https://doi.org/10.18103/mra.v13i1.6199.
Section
Research Articles

References

1. Safaee MM, Ames CP, Smith JS. Epidemiology and Socioeconomic Trends in Adult Spinal Deformity Care. Neurosurgery. 2020;87:25+.

2. Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082-1085. doi:10.1097/01.br s.0000160842.43482.cd

3. Koller H, Pfanz C, Meier O, et al. Factors influencing radiographic and clinical outcomes in adult scoliosis surgery: a study of 448 European patients. Eur Spine J. 2016;25(2):532-548. doi:10.1007/s00586-015-3898-x

4. Bae J, Theologis AA, Strom R, et al. Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance. J Neurosurg Spine. 2018;28(1):40-49. doi:10.3171/2017.5.SPINE161370

5. Drazin D, Shirzadi A, Rosner J, et al. Complications and outcomes after spinal deformity surgery in the elderly: review of the existing literature and future directions. Neurosurg Focus. 2011;31(4):E3. doi:10.3171/2011.7.FOCUS11145

6. Beschloss A, Dicindio C, Lombardi J, et al. Marked Increase in Spinal Deformity Surgery Throughout the United States. Spine (Phila Pa 1976). 2021;46(20):1402-1408. doi:10.1097/BRS.0 000000000004041

7. Charosky S, Guigui P, Blamoutier A, Roussouly P, Chopin D. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976). 2012;37(8): 693-700. doi:10.1097/BRS.0b013e31822ff5c1

8. Ham DW, Kim HJ, Choi JH, Park J, Lee J, Yeom JS. Validity of the global alignment proportion (GAP) score in predicting mechanical complications after adult spinal deformity surgery in elderly patients. Eur Spine J. 2021;30(5):1190-1198. doi:10.1007/s0 0586-021-06734-2

9. Kim HJ, Bridwell KH, Lenke LG, et al. Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine (Phila Pa 1976). 2014;39(9):E576-80. doi:10.1097/B RS.0000000000000246

10. Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G. Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976). 2008;33(20): 2179-2184.

11. Hassanzadeh H, Gupta S, Jain A, El Dafrawy MH, Skolasky RL, Kebaish KM. Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform. 2013;1(4):299-305.

12. Yagi M, Rahm M, Gaines R, et al. Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity. Spine (Phila Pa 1976). 2014; 39(10):E607-E614.

13. Kim HJ, Bridwell KH, Lenke LG, et al. Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976). 2013;38(11):896-901.

14. Hostin RA, Yeramaneni S, Gum JL, Smith JS. Clinical and Economic Impact of Proximal Junctional Kyphosis on Pediatric and Adult Spinal Deformity Patients. Int J Spine Surg. 2023;17(S2): S9-S17. doi:10.14444/8518

15. McCarthy IM, Hostin RA, O’Brien MF, et al. Analysis of the direct cost of surgery for four diagnostic categories of adult spinal deformity. The Spine Journal. 2013;13(12):1843-1848.

16. Fakhre E, Kelly MJ, Mo FF. Proximal junctional kyphosis. Semin Spine Surg. 2022;34(1):100926. doi:https://doi.org/10.1016/j.semss.2022.100926

17. Lee J, Park YS. Proximal Junctional Kyphosis: Diagnosis, Pathogenesis, and Treatment. Asian Spine J. 2016;10(3):593-600. doi:10.4184/asj.201 6.10.3.593

18. Shen T, Shahzad H, Sierra F, et al. Osteoporosis Treatment and Outcomes in Patients Undergoing Adult Spinal Deformity Surgery. World Neurosurg. 2024;190:e1018-e1024. doi:10.1016/j. wneu.2024.08.053

19. Yao YC, Elysee J, Lafage R, et al. Preoperative Hounsfield Units at the Planned Upper Instrumented Vertebrae May Predict Proximal Junctional Kyphosis in Adult Spinal Deformity. Spine (Phila Pa 1976). 2021;46(3):E174-E180. doi:10.1097/BRS.0000000000003798

20. Yagi M, Ohne H, Konomi T, et al. Teriparatide improves volumetric bone mineral density and fine bone structure in the UIV+1 vertebra, and reduces bone failure type PJK after surgery for adult spinal deformity. Osteoporos Int. 2016;27(12):3495-3502. doi:10.1007/s00198-016-3676-6

21. Puvanesarajah V, Shen FH, Cancienne JM, et al. Risk factors for revision surgery following primary adult spinal deformity surgery in patients 65 years and older. Journal of Neurosurgery: Spine SPI. 2016;25(4):486-493. doi:10.3171/2016.2.SPIN E151345

22. Varshneya K, Jokhai RT, Fatemi P, et al. Predictors of 2-year reoperation in Medicare patients undergoing primary thoracolumbar deformity surgery. J Neurosurg Spine. Published online July 2020:1-5. doi:10.3171/2020.5.SPINE191425

23. Noh SH, Ha Y, Obeid I, et al. Modified global alignment and proportion scoring with body mass index and bone mineral density (GAPB) for improving predictions of mechanical complications after adult spinal deformity surgery. Spine J. 2020; 20(5):776-784. doi:10.1016/j.spinee.2019.11.006

24. Mohanty S, Sardar ZM, Hassan FM, Lombardi JM, Lehman RA, Lenke LG. Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density. J Bone Joint Surg Am. 2024;106(3):206-217. doi:10.2106/JBJS.23.00272

25. Amin RM, Raad M, Jain A, et al. Risk factors for nonroutine discharge in adult spinal deformity surgery. The Spine Journal. 2019;19(2):357-363.

26. Zhang D, Gao X, Ding W, Cui H. Predictors and correlative factors for low back pain after long fusion arthrodesis in patients with adult scoliosis. Adv Ther. 2021;38(7):3803-3815.

27. Passias PG, Bortz CA, Lafage V, et al. Durability of satisfactory functional outcomes following surgical adult spinal deformity correction: a 3-year survivorship analysis. Operative Neurosurgery. 2020;18(2):118-125.

28. Varshneya K, Bhattacharjya A, Jokhai RT, et al. The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients. European Spine Journal. 2022;31(1):88-94. doi:10.1007/s00 586-021-06985-z

29. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11):2520-2526. doi:10.1002/jb mr.2269

30. Kuprys TK, Steinmetz LM, Fischer CR, et al. Preoperative Assessment of Bone Quality in Spine Deformity Surgery: Correlation With Clinical Practice and Published Recommendations. Spine (Phila Pa 1976). 2019;44(12):E735-E741. doi:10.1097/BRS.0 000000000002956

31. Dipaola CP, Bible JE, Biswas D, Dipaola M, Grauer JN, Rechtine GR. Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis. Spine J. 2009;9(7):537-544. doi:10.1016/j.spinee.2009.02.005

32. Gupta A, Upadhyaya S, Patel A, et al. DEXA sensitivity analysis in patients with adult spinal deformity. Spine J. 2020;20(2):174-180. doi:10.10 16/j.spinee.2019.08.011

33. Arora A, Cummins DD, Wague A, et al. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform. 2023;11(4):773-785. doi:10.1007/s43390-023-00654-5

34. Li QD, Yang JS, He BR. Risk factors for proximal junctional kyphosis after posterior long-segment internal fixation for chronic symptomatic osteoporotic thoracolumbar fractures with kyphosis. BMC Surg. 2022;22(1):189.

35. Hyun SJ, Kim YJ, Rhim SC. Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area. Spine J. 2016;16(9):1095-1101.

36. Hills JM, Weisenthal BM, Wanner JP. A patient-specific approach to alignment and proximal junctional kyphosis risk assessment in adult spinal deformity surgery: development and validation of a predictive tool. Clin Spine Surg. 2022;35(6):256-263.

37. Wang H, Ding W, Ma L, Zhang L, Yang D. Prevention of proximal junctional kyphosis: are polyaxial pedicle screws superior to monoaxial pedicle screws at the upper instrumented vertebrae? World Neurosurg. 2017;101:405-415.

38. Wang Q, Wang C, Zhang X. Correlation of vertebral trabecular attenuation in Hounsfield units and the upper instrumented vertebra with proximal junctional failure after surgical treatment of degenerative lumbar disease. J Neurosurg Spine. 2021;34(3):456-463.

39. Yagi M, Fujita N, Tsuji O. Low bone-mineral density is a significant risk for proximal junctional failure after surgical correction of adult spinal deformity: a propensity score-matched analysis. Spine (Phila Pa 1976). 2018;43(7):485-491.

40. Yuan L, Zeng Y, Chen Z, Li W, Zhang X, Mai S. Degenerative lumbar scoliosis patients with proximal junctional kyphosis have lower muscularity, fatty degeneration at the lumbar area. Eur Spine J. 2021;30(5):1133-1143.

41. Chen JW, McCandless MG, Bhandarkar AR, et al. The association between bone mineral density and proximal junctional kyphosis in adult spinal deformity: a systematic review and meta-analysis. J Neurosurg Spine. 2023;39(1):82-91. doi:https://doi.org/10.3171/2023.2.SPINE221101

42. Kim JS, Phan K, Cheung ZB. Surgical, radiographic, and patient-related risk factors for proximal junctional kyphosis: a meta-analysis. Global Spine J. 2019;9(1):32-40.

43. Park SJ, Lee CS, Park JS, Jeon CY, Ma CH, Shin TS. Risk factors for radiographic progression of proximal junctional fracture in patients undergoing surgical treatment for adult spinal deformity. J Neurosurg Spine. 2023;39(6):765-773. doi:https://doi.org/10.3171/2023.7.SPINE23103

44. Park SJ, Lee CS, Chung SS, Lee JY, Kang SS, Park SH. Different Risk Factors of Proximal Junctional Kyphosis and Proximal Junctional Failure Following Long Instrumented Fusion to the Sacrum for Adult Spinal Deformity: Survivorship Analysis of 160 Patients. Neurosurgery. 2017;80 (2):279-286. doi:10.1227/NEU.0000000000001240

45. Halvorson TL, Kelley LA, Thomas KA, et al. Effects of Bone Mineral Density on Pedicle Screw Fixation. Spine (Phila Pa 1976). 1994;19(21):2415-2420. doi:10.1097/00007632-199411000-00008

46. Shea TM, Laun J, Gonzalez-Blohm SA, et al. Designs and techniques that improve the pullout strength of pedicle screws in osteoporotic vertebrae: current status. Biomed Res Int. 2014;2014:748393. doi:10.1155/2014/748393

47. Gupta A, Cha T, Schwab J, et al. Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J. 2021;21(1):134-140. doi:10.1016/j.spinee.2020.08.002

48. Eastell R, Mitlak BH, Wang Y, Hu M, Fitzpatrick LA, Black DM. Bone turnover markers to explain changes in lumbar spine BMD with abaloparatide and teriparatide: results from ACTIVE. Osteoporos Int. 2019;30(3):667-673. doi:10.1007/s 00198-018-04819-1

49. Sahbani K, Cardozo CP, Bauman WA, Tawfeek HA. Abaloparatide exhibits greater osteoanabolic response and higher cAMP stimulation and β-arrestin recruitment than teriparatide. Physiol Rep. 2019;7(19):e14225. doi:10.14814/phy2.14225

50. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar posterolateral fusion in women with postmenopausal osteoporosis: prospective study. Spine (Phila Pa 1976). 2012;37(23):E1464-8. doi:10.1097/BRS.0b013e31826ca2a8