背景:虽然已经对近端交界衰竭(PJF)进行了大量研究,急性和迟发性PJF的临床意义仍然知之甚少。
目的:本研究的主要目的是分别探讨急性和延迟性PJF的危险因素。其次,我们旨在评估每种失效模式的发生率及其与急性和延迟PJF相关的临床后果.
方法:回顾性对比研究。
方法:年龄≥60岁的患者接受了5级以上骶骨融合的畸形矫正。
方法:风险因素,故障模式,和患者报告的结果测量(PROM)方法:急性PJF定义为6个月内发生的PJF,而延迟PJF发生在6个月后。通过比较三组之间的各种临床和影像学参数来分析危险因素:急性,和延迟PJF组。故障模式,包括软组织衰竭,椎骨骨折,固定失败,和脊髓病,在这些群体中进行了比较。通过评估近端交界角(PJA)的变化来评估PJF发展后的临床子序列,修订率,和患者报告的结果测量(PROM)。
结果:一项由363名患者组成的研究队列被纳入分析。其中,156名患者经历了PJF,急性PJF组87例(55.8%),延迟PJF组69例(44.2%)。多变量分析表明,年龄较大(比值比[OR]=1.057,95%置信区间[CI]=1.002-1.118),骨质疏松症(OR=2.149,95%CI=1.074-4.300),美国麻醉学会ASA评分较高(OR=2.150,95%CI=1.089-4.245),与年龄调整后的骨盆发病率-腰椎前凸度目标(OR=4.031,95%CI=1.962-8.280)相关的过度矫正被确定为急性PJF发展的危险因素.另一方面,发现高体重指数(OR=1.150,95%CI=1.049-1.251)和位于≤T10的最上层器械椎骨(OR=2.267,95%CI=1.205-4.268)与PJF的延迟发生有关。没有发现射线照相参数与延迟PJF的发展有关。就故障模式而言,椎体骨折和内固定失败更常见于急性PJF,而软组织衰竭和脊髓病在延迟性PJF中更占优势。与延迟PJF组相比,急性PJF组的临床病程更具侵略性,PJA的增加幅度更大,更高的修订率,更糟糕的PROM。
结论:本研究表明急性和延迟性PJF的危险因素不同。发现相对于年龄调整后的PI-LL目标的过度校正增加了急性PJF的风险,但对延迟PJF的发展没有影响。因此,需要建立不同的手术策略来缓解急性和延迟性PJF.
BACKGROUND: While numerous studies have been conducted on proximal junctional failure (PJF), the clinical significance of
acute and delayed PJF remains poorly understood.
OBJECTIVE: The primary object of this study is to investigate the risk factors separately for
acute and delayed PJF. Secondly, we aim to assess the incidence of each failure mode and their clinical consequences in relation to
acute and delayed PJF.
METHODS: Retrospective comparative study.
METHODS: Patients aged ≥60 years who underwent deformity correction with ≥5-level fusion to sacrum.
METHODS: Risk factor, failure modes, and patient-reported outcome measure (PROM) METHODS:
Acute PJF is defined as PJF occurring within 6 months, while delayed PJF occurring after 6 months. Risk factors were analyzed by comparing various clinical and radiographic parameters among three groups: no, acute, and delayed PJF groups. The failure modes, including soft tissue failure, vertebral fracture, fixation failure, and myelopathy, were compared among these groups. The clinical subsequences after PJF development were evaluated by assessing the change in proximal junctional angle (PJA), revision rate, and patient-reported outcome measure (PROM).
RESULTS: A study cohort of 363 patients was included in the analysis. Among them, 156 patients experienced PJF, with 87 patients (55.8%) in the acute PJF group and 69 patients (44.2%) in the delayed PJF group. Multivariate analyses showed that older age (Odds ratio [OR] = 1.057, 95% confidence interval [CI] = 1.002 - 1.118), osteoporosis (OR=2.149, 95% CI = 1.074 - 4.300), high American Society of Anesthesiology ASA score (OR=2.150, 95% CI = 1.089 - 4.245), and overcorrection relative to the age-adjusted pelvic incidence - lumbar lordosis target (OR=4.031, 95% CI = 1.962 - 8.280) were identified as risk factors for the development of acute PJF. On the other hand, a high body mass index (OR=1.150, 95% CI = 1.049 - 1.251) and an uppermost instrumented vertebra located at ≤ T10 (OR=2.267, 95% CI = 1.205 - 4.268) were found to be associated with delayed occurrence of PJF. No radiographic parameters were found to be related to the development of delayed PJF. In terms of failure modes, vertebral fracture and fixation failure were more commonly observed in acute PJF, while soft tissue failure and myelopathy were more predominant in delayed PJF. The clinical course was more aggressive in the
acute PJF group compared to the delayed PJF group, as evidenced by a greater increase in PJA, a higher revision rate, and worse PROM.
CONCLUSIONS: This study demonstrated different risk factors between the acute and delayed PJF. It was found that overcorrection relative to the age-adjusted PI-LL target increased the risk of acute PJF, but had no impact on the development of delayed PJF. Therefore, a different surgical strategy needs to be established to mitigate both acute and delayed PJF.