• Alan H Daniels, Daniel B C Reid, Wesley M Durand, Breton Line, Peter Passias, Han Jo Kim, Themistocles Protopsaltis, Virginie LaFage, Justin S Smith, Christopher Shaffrey, Munish Gupta, Eric Klineberg, Frank Schwab, Doug Burton, Shay Bess, Christopher Ames, Robert A Hart, and International Spine Study Group.
• Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA. Electronic address: alan_daniels@brown.edu.
• World Neurosurg. 2020 Jul 1; 139: e449-e454.

ObjectiveThis case series examined patients undergoing caudal extension of prior fusion without alteration of the prior upper instrumented vertebra (UIV) to assess patient outcomes and rates of proximal junctional kyphosis (PJK)/proximal junctional failure (PJF).MethodsPatients eligible for 2-year minimum follow-up undergoing caudal extension of prior fusion with unchanged UIVs were identified. These patients were evaluated for PJK/PJF, and patient reported outcomes were recorded.ResultsIn total, 40 patients were included. Mean follow-up duration was 2.2 ± 0.3 years. Patients in this cohort had poor preoperative sagittal alignment (pelvic incidence minus lumbar lordosis [PI-LL] 26.7°, T1 pelvic angle [TPA] 29.0°, sagittal vertical axis [SVA] 93.4 mm) and achieved substantial sagittal correction (ΔSVA -62.2 mm, ΔPI-LL -19.8°, ΔTPA -11.1°) after caudal extension surgery. At final follow-up, there was a 0% rate of PJF among patients undergoing caudal extension of previous fusion without creation of a new UIV, but 27.5% of patients experienced PJK. Patients experienced significant improvement in both the Oswestry Disability Index and Scoliosis Research Society-22r total score at 2 years postoperatively (P < 0.05). In total, 7.5% (n = 3) of patients underwent further revision, at an average of 1.1 ± 0.54 years after the surgery with unaltered UIV. All 3 of these patients underwent revision for rod fracture with no revisions for PJK/PJF.ConclusionsPatients undergoing caudal extension of previous fusions for sagittal alignment correction have high rates of clinical success, low revision surgery rates, and very low rates of PJF. Minimizing repetitive tissue trauma at the UIV may result in decreased PJF risk because the PJF rate in this cohort of patients with unaltered UIV is below historical PJF rates of patients undergoing sagittal balance correction.Copyright © 2020 Elsevier Inc. All rights reserved.

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