• Richard Hostin, Ian McCarthy, Michael OʼBrien, Shay Bess, Breton Line, Oheneba Boachie-Adjei, Doug Burton, Munish Gupta, Christopher Ames, Vedat Deviren, Khaled Kebaish, Christopher Shaffrey, Kirkham Wood, Robert Hart, and International Spine Study Group.
• *Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX; †Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX; ‡Southern Methodist University, Department of Economics Dallas, TX; §Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO; ¶Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY; ‖Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS; **Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA ††Department of Neurosurgery, University of California San Francisco, San Francisco, CA; ‡‡Department of Orthopaedic Surgery, University of California San Francisco, CA; §§Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD; ¶¶Department of Neurosurgery, University of Virginia, Charlottesville, VA; ‖‖Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; ***Department of Orthopaedic Surgery, Oregon Health Sciences University, Portland, OR; †††Denver, CO.
• Spine. 2013 May 20;38(12):1008-15.

Study DesignMulticenter, retrospective series.ObjectiveTo analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity.Summary Of Background DataEarly proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear.MethodsA total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery.ResultsSixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01).ConclusionAPJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

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