Post-Operative Spinal Deformities

(Kyphosis, Nonunion,
and Loss of Motion Segment)

R a v an n o F an i z za H ar a ha p
BACKGROUND

Lumbar spine instrumentation and fusion is a commonly indicated treatment for

infection, tumors, trauma, deformity, and degenerative disease.

Unfortunately, these surgeries can result in unplanned complications such as

proximal disease, failure of fusion, and loss of motion with associated adjacent
level disease, all of which can be problematic for patients.

The purpose of this chapter is to discuss each of these fusion-related complications

and provide some insight into how to properly manage them.
 Proximal Junctional Kyphosis

PJK has traditionally been defined by

a 10 degree or greater increase in
kyphosis at the proximal junction as
measured on a sagittal radiograph
with a Cobb angle from the caudal
end plate of the uppermost
instrumented vertebrae (UIV) to the
cephalad end plate of the vertebrae
two segments cranial to the UIV.

PJK is associated with significant

pain, neurologic deficit, and need for
revision surgery.
The term proximal junctional failure (PJF) is used to define this group and to
distinguish it from PJK. PJF is associated not only with an increase in kyphosis but
also with structural failure. The structural failure occurs at either the UIV or the
vertebrae immediately proximal to the fusion construct (UIV +1).
Structural failure is considered a vertebral body fracture, disruption of the
posterior osseoligamentous complex, or both.

Risk factors for developing PJK/PJF have been identified and include advanced
patient age, poor bone quality, posterior spinal ligamentous disruption, instrumentation
rigidity, fusion to the sacrum, and postoperative spinal alignment.
Several strategies have been proposed to mitigate the
occurrence of PJK/PJF, including preservation of the
posterior ligament complex and adjacent facet joints,
use of vertebral augmentation with polymethyl
methacrylate (PMMA) to prevent vertebral compression
fractures, and use of less rigid fixation at the proximal
terminal junction of the construct with transitional rods,
transverse process hooks, and dynamic stabilization
techniques.

One technique that does seem to offer the potential to

reduce the occurrence of PJK/PJF is the use of
junctional tethers. Using a polyester tether such as
woven polyethylene Mersilene tape (Ethicon,
Somerville, NJ), the spinous processes are interwoven
in an attempt to dissipate forces at the proximal junction.
Current management for PJK involves
both conservative and surgical
interventions. When diagnosed
radiographically, PJK may be followed with
routine imaging and close observation.
Some patients will remain asymptomatic.
Other patients may be managed by pain
medications, physical therapy to
strengthen the back, or epidural injections.
 Non-Union

Pseudarthrosis is a well-reported
complication of lumbar spine surgery.
Diagnosis can be difficult because
Its diagnosis is based on appropriate
symptoms are not specific to pseudarthrosis
clinical history and imaging findings
but may be attributable to other causes,
or implant failure, loss of fixation,
such as infection or adjacent segment
deformity, or radiolucencies.
disease (ASD).
A pain-free interval in the postoperative
Pseudarthrosis should be suspected
period is a useful clue into the history.
when a patient presents with
Patients with no symptom relief
recurrent pain and/or neurologic
postoperatively should be studied further to
symptoms during long-term
rule out additional causes.
follow-up from fusion or in the
presence of instrumentation failure.
 Local factors that can lead to nonunions include poor preparation or decortication of the fusion surface,
insufficient viable graft material, vascular insufficiency, smoking, poor nutrition, or metabolic problems.
Meticulous surgical preparation and adequate quality bone graft will minimize the risk for fusion failure.

Additional methods used to detect

pseudarthrosis include bone
Computed tomography
scintigraphy and positron emission
(CT) imaging has the
tomography (PET) scans.
strongest correlation of
Plain radiographs are
fusion assessment and
often the initial assessment PET scans detect gamma ray
should be obtained if a
for pseudarthrosis. emission from positron-emitting
nonunion is in question.
radioactive tracers, which have an
Plain radiographs relatively affinity for metabolically active
Findings:
low cost, but the cells. It has recently been
absence of continuous
radiographic presentation suggested that tracers, which are
trabecular bone between
of nonunions can vary. used more commonly for detection
adjacent vertebrae, gas in
of infections and neoplasm, can
the disc space, and
also measure bone graft healing by
periimplant radiolucency.
correlating increased uptake at the
fusion site.
The treatment of pseudarthrosis varies but is almost always surgical.

In cases of asymptomatic patients, they may be observed and followed closely with radiographs and
routine evaluation.
When symptomatic, patients will often experience pain in the axial spine with occasional radicular
symptoms.

A delayed fusion with no evidence of instrumentation loosening may be treated with bracing,
activity limitation, and observation.
Primary principles of surgery include stabilization of the existing posterior fixation and regrafting.
Treatments may require a circumferential fusion with anterior lumbar interbody fusion (ALIF) or
lateral lumbar or posterior lumbar interbody fusion.

The best treatment for pseudarthrosis is to prevent it from occurring at the initial operation.
Improvements in bone graft materials, instrumentation, and techniques have all led to decreased
rates of nonunion.

Risk factors such as alcoholism, osteoporosis, advanced age,

malnutrition, and tobacco use have all been attributed to decreased
fusion rates.
 Loss of Motion Segment and
Adjacent Segment Disease

The risk factors that lead to ASD:

ASD is a clinical deterioration of -those over age 60
adjacent vertebral levels after a -postmenopausal women
spine fusion. -positive smoking history
ASD occurs as a result of increased -degenerative scoliosis increases
degeneration of spine levels the risk of ASD
neighboring a fused segment,
theoretically from increased
biomechanical stress and physiologic
loading.
Treatment for ASD is complicated by the risk associated with revision surgery
and the potential for further degenerative disease.
Priorities should be dictated by the patient’s age and degree of symptoms, with
conservative measures being appropriate in most cases.
When surgical management is indicated, restoring and maintaining spinal
alignment is a proven way to improve patient outcomes and reduce the
incidence of future ASD.
 SUMMARY

• In all phases of spine care, proper attention must be paid to pelvic parameters and sagittal balance. Any
surgical intervention must prioritize restoration and maintenance of lumbar lordosis with attention
to spinal alignment.
• Although some risk factors are unavoidable (advanced age, scoliosis), others such as quality of bone,
smoking cessation, and nutrition should be maximized before surgery. We routinely consult endocrine for help
in managing osteopenia and osteoporosis.
• Meticulous attention to proper fusion at the initial surgery is the best prevention for pseudarthrosis. When a
nonunion does occur, extra effort must be made to remove fibrous tissue from bone surfaces and
prepare a new arthrodesis surface.
Thank you