title: Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1?
abstract: METHODS
  A retrospective comparison study.
  
  
  OBJECTIVE
  To compare the postoperative proximal junctional change and revision prevalence as influenced by 3 different proximal levels after adult lumbar deformity instrumented fusion from the distal thoracic/upper lumbar spine (T9-L2) to L5 or S1.
  
  
  BACKGROUND
  Few comparative studies on postoperative sagittal plane change and revision prevalence as influenced by 3 different proximal levels after adult lumbar deformity instrumented fusion from the distal thoracic/upper lumbar spine (T9-L2) to L5 or S1 have been published. Many surgeons have hypothesized that stopping proximally in the upper lumbar spine (L1 or L2) or the thoracolumbar junction (T11 or T12) would lead to a high percentage of rapid proximal degeneration, kyphosis, and decompensation because of the concentration of stress on these relatively mobile segments. Therein, many surgeons have felt it is unsafe to stop at these regions of the spine and it is better to always stop proximally at T9 or T10.
  
  
  METHODS
  A clinical and radiographic assessment in addition to revision prevalence of 125 adult lumbar deformity patients (average age 57.1 year) who underwent long (average 7.1 vertebrae) segmental posterior spinal instrumented fusion from the distal thoracic/upper lumbar spine (T9-L2) to L5 or S1 with a minimum 2-year follow-up (2-19.8 year follow-up) were compared as influenced by T9-T10 (group 1, n = 37), T11-T12 (group 2, n = 49), and L1-L2 (group 3, n = 39) proximal fusion levels. The revision prevalence and sagittal Cobb angle change at the proximal junction after surgery were compared.
  
  
  RESULTS
  Three groups demonstrated nonsignificant differences in the prevalence of proximal junctional kyphosis (group 1 51% vs. group 2 55% vs. group 3 36%, P = 0.20) and revision (group 1 24% vs. group 2 24% vs. group 3 26%, P = 0.99) at the ultimate follow-up. Subsequent proximal junctional angle and sagittal vertical axis changes between the ultimate follow-up and preoperative (P = 0.10 and 0.46 respectively) were not significantly different. The SRS total and all subscale outcomes scores among the 3 groups did not demonstrate significant differences (P > 0.50).
  
  
  CONCLUSIONS
  Three different proximal fusion levels did not demonstrate significant radiographic and clinical outcomes or revision prevalence after surgery. Therefore the more distal proximal fusion level at a neutral and stable vertebra may be satisfactory.
authors.affiliation: Washington University Medical Center, St. Louis, MO, USA.
authors.forename: Yongjung J
authors.initials: YJ
authors.lastname: Kim
authors.forename: Keith H
authors.initials: KH
authors.lastname: Bridwell
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Seungchul
authors.initials: S
authors.lastname: Rhim
authors.forename: Young-Woo
authors.initials: YW
authors.lastname: Kim
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007738:Kyphosis / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000517:prevention & control*; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000517:prevention & control*; D015995:Prevalence; D011859:Radiography; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012447:Sacrum / Q000000981:diagnostic imaging / Q000601:surgery; D012600:Scoliosis / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods* / Q000706:statistics & numerical data; D013131:Spine / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D016896:Treatment Outcome