YUAN Lei,ZHANG Xinling,ZENG Yan.Distal junctional problem after posterior long instrumented spinal fusion in degenerative lumbar scoliosis[J].Chinese Journal of Spine and Spinal Cord,2019,(6):505-513.
Distal junctional problem after posterior long instrumented spinal fusion in degenerative lumbar scoliosis
Received:February 26, 2019  Revised:May 27, 2019
English Keywords:Degenerative lumbar scoliosis  Long instrumented spinal fusion  Distal junctional problem  Mechanical complications
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Author NameAffiliation
YUAN Lei Orthopaedic Department, Peking University Third Hospital, Beijing, 100191, China 
ZHANG Xinling 北京大学第三医院骨科 100191 北京市 
ZENG Yan 北京大学第三医院骨科 100191 北京市 
陈仲强  
刘寅昊  
李危石  
齐 强  
郭昭庆  
孙垂国  
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English Abstract:
  【Abstract】 Objectives: To evaluate the incidence, risk factor, and clinical influence of distal junctional problem(DJP) after long instrumented spinal fusion in degenerative lumbar scoliosis(DLS). Methods: From April 2009 to October 2017, a total of 132 DLS patients who underwent one stage posterior long instrumented spinal fusion in our spinal center was reviewed. The inclusion criteria included: ①age≥40 years; ②fusion level≥4 levels; ③follow-up time≥1 years. Patients with DJP during follow-up were included in the DJP group(13 cases), and patients without mechanical complications were included in the control group(41 cases). To investigate risk factors for DJP, three kinds of factors were statistically analyzed: ①patient-related risk factors including age, sex, body mass index(BMI), bone mineral density(BMD), T-score and so on; ②surgery-related risk factors including the number of instrumented levels, lowest instumented vertebra(LIV), osteotomy and interbody fusion; ③pre- and postoperative radiographic parameters including Cobb angle, vertebral axial rotation(Nash-Moe), apical vertebral translation(AVT), coronal vertical axis(CVA), thoracic kyphosis(TK), thoracolumbar kyphosis(TLK), lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT), sacral slope(SS), sagittal vertical axis(SVA), T1 pelvic angle(TPA), global tilt(GT) and so on. Preoperative and follow-up visual analog scale(VAS) for low back pain and leg pain, Oswestry disability index(ODI), Japanese Orthopaedic Association-29(JOA-29) scores, Scoliosis Research Society-22(SRS-22) scores and short form 36 health survey questionnaire(SF-36) scores were compared between the DJP group and the control group. Results: DJP was developed in 13 of the 132 patients(9.8%). The T-score in the DJP group was significantly lower than that in the control group, and the proportion of patients with osteopenia and osteoporosis in DJP patients was significantly higher than that in the control group. DJP patients had a higher preoperative TLK, a lower preoperative PT and a higher proportion of patients with preoperative SVA>70mm. Comparing with the control group, the DJP group had a higher postoperative TLK, a higher postoperative SVA and a higher proportion of sagittal imbalance(46.15% vs 14.63%, P=0.046). Multiple logistic regression analysis indicated that osteoporosis(OR=8.90, 95% CI=1.95-40.51, P=0.005) and immediately postoperative sagittal imbalance(OR=5.82, 95% CI=1.15-29.42, P=0.033) were independent risk factors of DJP. In the control group, all baseline quality of life score values had improved significantly at follow-up(P<0.05), while no significant improvement of ODI score, JOA score or SF-36 mental component summary scale(MCS) score was observed in the DJP group. The following scores were worse at final follow-up in the DJP group: VAS score for lumbar pain, ODI, JOA, SRS-22 pain, SRS-22 function, SRS subtotal score, SRS satisfaction, SF-36 phyisical component summary scale(PCS), SF-36 MCS score. Conclusions: Distal junctional problem occurred in 9.8% of DLS patients after long instrumented spinal fusion, and seriously affected the improvement of patients′ quality of life. Osteoporosis and immediately postoperative sagittal imbalance were independent risk factors of DJP.
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