Techniques for operative correction of proximal junctional kyphosis of the upper thoracic spine

Retrospective study of a consecutive series of patients treated for proximal junctional kyphosis (PJK) of the upper thoracic and cervicothoracic spine.

To discuss corrective techniques for the management of symptomatic kyphosis at the junction of fused and mobile segments of the upper thoracic and cervicothoracic spine in patients who complain of pain, neurological deficit, ambulatory difficulty, and/or social isolation.

PJK is an unfortunately common, but important, complication seen in long instrumented fusions to the upper thoracic and cervicothoracic spine. Although often asymptomatic, its incidence and prevalence warrant a discussion on treatment options for symptomatic patients.

After the institutional review board confirmed approval, we retrospectively analyzed patients who received treatment of PJK from 2003 to 2009. Segmental instrumentation and intraoperative neurophysiological monitoring were used in all patients. Data acquisition was performed by reviewing electronic medical records and radiographs. Inclusion criteria were patients who underwent surgical correction of PJK of the cervicothoracic and upper thoracic spine and had more than 2-year follow-up. Preoperative lumbar lordosis, preoperative thoracic kyphosis, pre- and postoperative sagittal balance, and sagittal proximal junctional Cobb angle were obtained. All corrective procedures were performed in 2 stages, each patient receiving cervical traction between cases.

Inclusion criteria were met in 7 patients (5 women and 2 men), with mean age of 55 years (range, 18-80 years). Six patients received multilevel Smith-Petersen osteotomies, with 2 patients receiving rib osteotomies, and 1 patient received a vertebral column resection. The mean preoperative and postoperative proximal junctional Cobb angles were 45° (range, 14°-89.7°) and 14° (range, 3.0°-38.0°), respectively. The mean degree of correction was 31° (range, 11°-79.2°). All patients had maintained or improved sagittal balance. No patient sustained a temporary or permanent neurological deficit after correction related to surgery. All patients had 2-year follow-up, and there were no mortalities.

For a selected cohort of patients who develop PJK of the upper thoracic and cervicothoracic spine, osteotomies, cervical traction, and intraoperative manual reduction provide a significant improvement of proximal junctional Cobb angles. To our knowledge, this is the first study to address treatment for symptomatic patients with this condition.