title: Association between bicortical screw fixation at upper instrumented vertebra and risk for upper instrumented vertebra fracture.
abstract: OBJECTIVE The aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery. METHODS A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9-L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV. RESULTS The mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence-LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02). CONCLUSIONS Bicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.
authors.affiliation: Department of Neurosurgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University Graduate School of Medicine, Jinju; and.
authors.forename: Young-Seop
authors.initials: YS
authors.lastname: Park
authors.affiliation: Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi, Korea.
authors.forename: Seung-Jae
authors.initials: SJ
authors.lastname: Hyun
authors.affiliation: Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi, Korea.
authors.forename: Ho Yong
authors.initials: HY
authors.lastname: Choi
authors.affiliation: Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi, Korea.
authors.forename: Ki-Jeong
authors.initials: KJ
authors.lastname: Kim
authors.affiliation: Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi, Korea.
authors.forename: Tae-Ahn
authors.initials: TA
authors.lastname: Jahng
mesh_terms: D000368:Aged; D015519:Bone Density; D001863:Bone Screws / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D050815:Fractures, Compression / Q000000981:diagnostic imaging / Q000453:epidemiology; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000378:metabolism / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019904:Polymethyl Methacrylate; D012189:Retrospective Studies; D012306:Risk; D013121:Spinal Curvatures / Q000000981:diagnostic imaging / Q000378:metabolism / Q000601:surgery; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000209:etiology*; D013123:Spinal Fusion / Q000009:adverse effects* / Q000295:instrumentation; D016896:Treatment Outcome
chemical_list: D019904:Polymethyl Methacrylate
keywords: APJF = acute proximal junctional failure; BMD = bone mineral density; LIV = lower instrumented vertebra; LL = lumbar lordosis; ODI = Oswestry Disability Index; PI = pelvic incidence; PJF = proximal junctional failure; PJK = proximal junctional kyphosis; PMMA = polymethylmethacrylate; SVA = sagittal vertical axis; UIV = upper instrumented vertebra; UIV compression fracture; UIV screw fixation; acute proximal junctional failure; bicortical screw fixation; surgical technique; upper instrumented vertebra