Preliminary report on the flexible rod technique for prevention of proximal junctional kyphosis following long-segment fusion to the sacrum in adult spinal deformity

Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Won-Ju Shin, Sang Kyu Im, Seong Jin Cho
Journal of Neurosurgery. Spine 2019 July 12, : 1-8

OBJECTIVE: The incidence of proximal junctional kyphosis (PJK) after long-segment fixation in patients with adult spinal deformity (ASD) has been reported to range from 17% to 61.7%. Recent studies have reported using "hybrid" techniques in which semirigid fixation is introduced between the fused and flexible segments at the proximal level to allow a more gradual transition. The authors used these hybrid techniques in a clinical setting and analyzed PJK to evaluate the usefulness of the flexible rod (FR) technique.

METHODS: The authors retrospectively selected 77 patients with lumbar degenerative kyphosis (LDK) who underwent sagittal correction and long-segment fixation and had follow-up for > 1 year. An FR was used in 30 of the 77 patients. PJK development and spinal sagittal changes were analyzed in the FR and non-FR groups, and the predictive factors of PJK between a PJK group and a non-PJK group were compared.

RESULTS: The patient population comprised 77 patients (75 females and 2 males) with a mean (± SD) follow-up of 32.0 ± 12.7 months (36.7 ± 9.8 months in the non-FR group and 16.8 ± 4.7 months in the FR group) and mean (± SD) age of 71.7 ± 5.1 years. Sagittal balance was well maintained at final follow-up (10.5 and 1.5 mm) in the non-FR and FR groups, respectively. Thoracic kyphosis (TK) and lumbar lordosis (LL) were improved in both groups, without significant differences between the two (p > 0.05). PJK occurred in 28 cases (36.4%) in total, 3 (10%) in the FR and 25 (53.2%) in the non-FR group (p < 0.001). Postoperatively, PJK was observed at an average of 8.9 months in the non-FR group and 1 month in the FR group. No significant differences in the incidence of PJK regarding patient factors or radiological parameters were found between the PJK group and non-PJK group (p > 0.05). However, FR (vs non-FR) and interbody fusion except L5-S1 using oblique lumbar interbody fusion (vs non-oblique lumbar interbody fusion), demonstrated a significantly lower PJK prevalence (p < 0.001 and p = 0.044) among the surgical factors.

CONCLUSIONS: PJK was reduced after surgical treatment with the FR in the patients with LDK. Solid long-segment fixation and the use of the FR may become another surgical option for spine surgeons who plan and make decisions regarding spine reconstruction surgery for patients with ASD.

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