title: Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity.
abstract: METHODS
  Multicenter, retrospective, consecutive case series.
  
  
  OBJECTIVE
  This study aims to identify demographic and radiographical characteristics that influence the decision to perform revision surgery among patients with proximal junctional failure (PJF).
  
  
  BACKGROUND
  Revision rates after PJF remain relatively high, yet the decision criteria for performing revision surgical procedures are not uniform and vary by surgeon. A better understanding of the factors that impact the decision to perform revision surgery is important in order to improve efficiency of surgical treatment of adult spinal deformity.
  
  
  METHODS
  A cohort of 57 patients with PJF was identified retrospectively from 1218 consecutive patients with adult spinal deformity. PJF was identified on the basis of 10° postoperative increase in kyphosis between upper instrumented vertebra (UIV) and UIV +2, along with 1 or more of the following: fracture of the vertebral body of UIV or UIV +1, posterior osseoligamentous disruption, or pullout of instrumentation at the UIV. Univariate statistical analysis was performed using t tests and Fisher exact tests. Multivariate analysis was performed using logistic regression.
  
  
  RESULTS
  Twenty-seven (47.4%) patients underwent revision surgery within 6 months of the index operation. Regression results revealed that patients with combined posterior/anterior approaches at index were significantly more likely to undergo revision (P = 0.001) as were patients with more extreme proximal junctional kyphosis angulation (P = 0.034). Patients sustaining trauma were also significantly more likely to undergo revision (P = 0.019). Variables approaching but not reaching significance as predictors of revision included female sex (P = 0.066) and higher sagittal vertical axis (SVA) (P = 0.090).
  
  
  CONCLUSIONS
  The decision to perform revision surgery is complicated and varies by surgeon. Factors that seem to influence this decision include traumatic etiology of PJF, severity of proximal junctional kyphosis angulation, higher SVA, and female sex. Factors that were expected to influence revision but had no statistical effect included soft tissue versus bony mode of failure, age, levels fused, and upper thoracic versus thoracolumbar proximal junction.
authors.affiliation: *Oregon Health Sciences University, Portland, OR †Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX; and ‡Southern Methodist University, Dallas, TX; §Baylor Scoliosis Center, Plano, TX ¶Rocky Mountain Scoliosis and Spine, Denver, CO ‖Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY **Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS ††Department of Orthopedic Surgery, University of California Davis, Sacramento, CA ‡‡Department of Neurological Surgery, University of California San Francisco, San Francisco, CA §§Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA; ¶¶Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD ‖‖Department of Neurological Surgery, University of Virginia, Charlottesville, VA ***Massachusetts General Hospital, Boston, MA; and †††Denver, CO.
authors.forename: Robert
authors.initials: R
authors.lastname: Hart
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: Brett
authors.initials: B
authors.lastname: Line
authors.forename: Oheneba Boachie
authors.initials: OB
authors.lastname: 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: Richard
authors.initials: R
authors.lastname: Hostin
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D012600:Scoliosis / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects; D013904:Thoracic Vertebrae / Q000473:pathology / Q000601:surgery*; D017211:Treatment Failure; D016896:Treatment Outcome