Tag Archive for: Junctional Kyphosis

Volume 3 | Issue 2 | October 2022-March 2023 | page: 119-124 | Ajay Krishnan, Shivakumar A Bali, Devanand Degulmadi, Shivanand Mayi, Ravi Ranjan, Vatsal Parmar, Pranav Charde, Vikrant Chauhan, Mirant B Dave, Denish Patel, Preety A Krishnan, Bharat R Dave

DOI: https://doi.org/10.13107/bbj.2022.v03i02.050

Authors: Ajay Krishnan [1], Shivakumar A Bali [1], Devanand Degulmadi [1], Shivanand Mayi [1], Ravi Ranjan [1], Vatsal Parmar [1], Pranav Charde [1], Vikrant Chauhan [1], Mirant B Dave [1], Denish Patel [1], Preety A Krishnan [2], Bharat R Dave [1]

[1] Department of Spine Surgery, Stavya Spine Hospital & Research Institute, Mithakhali, Ellisbridge, Ahmedabad, Gujarat, India.
[2] Department of Radiology, Stavya Spine Hospital & Research Institute, Mithakhali, Ellisbridge, Ahmedabad, Gujarat, India.

Address of Correspondence

Dr. Ajay Krishnan,
Spine Surgeon, Department of Spine Surgery, Stavya Spine Hospital & Research Institute, Mithakhali, Ellisbridge, Ahmedabad, Gujarat, India.
E-mail: drajaykrishnan@gmail.com

Abstract

Background: Revision spine surgery needing extension of fixation either require complete exposure of previously operated levels for rod exchange or can be managed by linking the new surgical construct (NSC) to primary surgical construct (PSC) with dominos. Presumptive long rod technique (PLRT) provides additional length of rod for domino placement.
Case report: 80-year male on conservative management developed acute cauda equina syndrome retention due to pre-existing multilevel lumbar stenosis and acute big sequestrated disc prolapse at L12. Emergent surgical intervention in form of L1 to L4 pedicle screw fixation with postero-lateral bone grafting and fragmentectomy was done. Peri-operative period was uneventful. He was started on Teriperatide 20mcg daily with progressive mobilization and physiotherapy. At 4 months of follow-up, he developed L1 osteoporotic fracture with proximal junctional kyphosis (PJK). Patient underwent T12-L1 interbody fusion with extension of fixation to T10 which required complete opening up of previous incision as it was an Indian implant set. A domino of larger foot print couldn’t be accommodated in the space available between L1- L2 screws. Owing to severe osteoporosis and degenerative changes at proximal levels, presumptive oversized rods were inserted with extra lengths of the rods left at proximal ends. This technique is labelled PLRT(presumptive long rod technique) at our institute. At 6 months of follow up, patient developed T10 osteoporotic fracture with PJK and patient was planned for extension of fixation upto T4. Since the extra lengths of rods were available at proximal ends, only the planned operative levels were exposed and it was connected to previous construct using the larger footprint domino. Patient improved clinically and was ambulatory. The patient expired at 18 months due to cardio-respiratory arrest unrelated to the spinal events.
Conclusion: Additional rod lengths intentionally left at adjacent levels during primary surgery where there is anticipation of PJK and adjacent segment disease (ASD) can be a boon when there is need for extension of fixation. These extra lengths of rod can be used to place dominos and connect PSC to NSC without the need for exposure of PSC levels for rod exchange, preventing complications especially in setups with economic constraints.
Keywords: Complex, Adult Spinal Deformity, Adjacent Segment, Junctional Kyphosis, Osteoporosis, Revision, Surgery, Multirod.

References

1. Welke B, Schwarze M, Hurschler C, Nebel D, Bergmann N, Daentzer D. In vitro investigation of two connector types for continuous rod construct to extend lumbar spinal instrumentation. Eur Spine J. 2018 Aug;27(8):1895-1904. doi: 10.1007/s00586-018-5664-3. Epub 2018 Jun 12. PMID: 29948326.
2. Chow DH, Luk KD, Evans JH, Leong JC. Effects of short anterior lumbar interbody fusion on biomechanics of neighboring unfused segments. Spine (Phila Pa 1976). 1996 Mar 1;21(5):549-55. doi: 10.1097/00007632-199603010-00004. PMID: 8852308.
3. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbo¬sacral fusion: review of the literature. Spine (Phila Pa 1976) 2004;29:1938-44.
4. Wang MY. Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation. J Neurosurg Spine 2013;18:4–12.
5. Eichholz KM, Ryken TC. Complications of revision spinal surgery. Neurosurg Focus 2003;15:E1.
6. Deyo RA, Mirza SK, Martin BI, KreuterW, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010;303: 1259–65.
7. Nasser R, Yadla S, Maltenfort MG, Harrop JS, Anderson DG, Vaccaro AR, et al. Complications in spine surgery. J Neurosurg Spine 2010;13:144–57.
8. Hashimoto K, Aizawa T, Kanno H, Itoi E. Adjacent segment degeneration after fusion spinal surgery-a systematic review. Int Orthop. 2019 Apr;43(4):987-993. doi: 10.1007/s00264-018-4241-z. Epub 2018 Nov 23. PMID: 30470865.
9. Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976) 2011;36:E60e8
10. Ogawa H, Hori H, Oshita H, Akaike A, Koyama Y, Shimizu T, Yamada K, Ishimaru D. Sublaminar wiring stabilization to prevent adjacent segment degeneration after lumbar spinal fusion. Arch Orthop Trauma Surg. 2009 Jul;129(7):873-8. doi: 10.1007/s00402-008-0725-4. Epub 2008 Aug 22. PMID: 18719930.
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 Jul;1(4):299-305. doi: 10.1016/j.jspd.2013.05.008. Epub 2013 Aug 2. PMID: 27927362.
12. Kanayama M, Hashimoto T, Shigenobu K et al (2001) Adjacentsegment morbidity after Graf ligamentoplasty compared with posterolateral lumbar fusion. J Neurosurg 95:5–10
13. Strauss PJ, Novotny JE, Wilder DG et al (1994) Multidirectional stability of the Graf system. Spine 19:965–972
14. Orthofix (2019).Connector system operative technique. https://www.orthofix.com/wp-content/uploads/2019/01/Connector-System-Operative-Technique.pdf
15. Zimmer biomet. Polaris spinal system domino rod connectors surgical technique guide. https://www.zimvie.com/content/dam/zimvie-corporate/en/products/specialties/spine/polaris-deformity-system/0328.1-GLBL-en-REV0318-Polaris-Domino-STG.pdf
16. Tatsumi rl, yoo ju, liu q, hart ra. Mechanical comparison of posterior instrumentation constructs for spinal fixation across the cervicothoracic junction. Spine (phila pa 1976). 2007;32: 1072-1076.
17. Tan QC, Huang JF, Bai H, Liu ZX, Huang XY, Zhao X, Yang Z, Du CF, Lei W, Wu ZX. Effects of Revision Rod Position on Spinal Construct Stability in Lumbar Revision Surgery: A Finite Element Study. Front Bioeng Biotechnol. 2022 Jan 5;9:799727. doi: 10.3389/fbioe.2021.799727. PMID: 35071208; PMCID: PMC8766337.
18. Chechik O, Fishkin M, Wientroub S, Ovadia D. A new pelvic rod system for the surgical correction and fixation of pelvic obliquity in pediatric neuromuscular scoliosis. J Child Orthop. 2011 Feb;5(1):41-8. doi: 10.1007/s11832-010-0318-y. Epub 2010 Dec 14. PMID: 22295048; PMCID: PMC3024490.
19. Senatus P, Chinthakunta SR, Vazifeh P, Khalil S. Biomechanical evaluation of a novel posterior integrated clamp that attaches to an existing posterior instrumentation for use in thoracolumbar revision. Asian Spine J. 2013 Mar;7(1):1-7. doi: 10.4184/asj.2013.7.1.1. Epub 2013 Mar 6. PMID: 23508231; PMCID: PMC3596578
20. Hohn EA, Chu B, Martin A, Yu E, Telles C, Leasure J, Lynch TL, Kondrashov D. The Pedicles Are Not the Densest Regions of the Lumbar Vertebrae: Implications for Bone Quality Assessment and Surgical Treatment Strategy. Global Spine J. 2017 Sep;7(6):567-571. doi: 10.1177/2192568217694141. Epub 2017 Apr 11. PMID: 28894687; PMCID: PMC5582706.
21. El Dafrawy MH, Adogwa O, Wegner AM et al (2020) Comprehensive classification system for multirod constructs across three column osteotomies: a reliability study. J Neurosurg Spine. https://doi. org/ 10. 3171/ 2020.6. SPINE 20678
22. Krishnan A, Raj A, Meena U, Degulmadi D, Rai RR, Mayi S, Dave M, Dave BR. RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique. Spine Deform. 2022 Apr 9. doi: 10.1007/s43390-022-00504-w. Epub ahead of print. PMID: 35397069.
23. Rathjen K, Wood M, McClung A, Vest Z. Clinical and radiographic results after implant removal in idio¬pathic scoliosis. Spine (Phila Pa 1976) 2007;32:2184- 8.
24. Pattanayak S. Expenditure Control: Key Features, Stages, and Actors.IMF 2016 March. https://www.imf.org/external/pubs/ft/tnm/2016/tnm1602a.pdf

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