title: Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity.
abstract: METHODS
  Multicenter, retrospective series.
  
  
  OBJECTIVE
  To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity.
  
  
  BACKGROUND
  Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  Sixty-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).
  
  
  CONCLUSIONS
  APJFs 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.
authors.affiliation: *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.
authors.forename: Richard
authors.initials: R
authors.lastname: Hostin
authors.forename: Ian
authors.initials: I
authors.lastname: McCarthy
authors.forename: Michael
authors.initials: M
authors.lastname: OʼBrien
authors.forename: Shay
authors.initials: S
authors.lastname: Bess
authors.forename: Breton
authors.initials: B
authors.lastname: Line
authors.forename: Oheneba
authors.initials: O
authors.lastname: Boachie-Adjei
authors.forename: Doug
authors.initials: D
authors.lastname: Burton
authors.forename: Munish
authors.initials: M
authors.lastname: Gupta
authors.forename: Christopher
authors.initials: C
authors.lastname: Ames
authors.forename: Vedat
authors.initials: V
authors.lastname: Deviren
authors.forename: Khaled
authors.initials: K
authors.lastname: Kebaish
authors.forename: Christopher
authors.initials: C
authors.lastname: Shaffrey
authors.forename: Kirkham
authors.initials: K
authors.lastname: Wood
authors.forename: Robert
authors.initials: R
authors.lastname: Hart
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D005260:Female; D006801:Humans; D015994:Incidence; D007738:Kyphosis / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D008141:Lordosis / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012600:Scoliosis / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D016103:Spinal Fractures / Q000175:diagnosis / Q000453:epidemiology*; D013123:Spinal Fusion / Q000009:adverse effects*; D013904:Thoracic Vertebrae / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology