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Can Discharge Radiographs Predict Junctional Complications? A Decision Tree Analysis.

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Standing pre-discharge radiographs can predict junctional complications after spinal fusion. Patients with a lower thoracic upper instrumented vertebra, a change in proximal junctional angle greater than 4.3°, and a discharge proximal junctional angle over 15.5° are at highest risk for proximal junctional failure.

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Area of Science:

  • Spine surgery
  • Orthopedic research
  • Radiographic analysis

Background:

  • Junctional complications like proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are significant concerns after long spinal fusion surgeries.
  • Predictive markers for these complications are crucial for improving patient outcomes and surgical planning.

Purpose of the Study:

  • To evaluate the efficacy of standing pre-discharge radiographs in predicting the development of PJK and PJF in adult spinal deformity patients.
  • To identify specific radiographic parameters on pre-discharge images that correlate with increased risk of junctional complications.

Main Methods:

  • A retrospective cohort study included adult spinal deformity patients who underwent lumbar fusion (≥5 levels, LIV pelvis).
  • Standing full-length radiographs were obtained before discharge.
  • Chi-square automatic interaction detection (CHAID) decision tree analysis was used to identify thresholds for proximal junctional angle (PJA) and its change (ΔPJA) associated with PJK/PJF risk.

Main Results:

  • The study analyzed 117 patients, stratifying them into No PJK (54.7%), PJK (33.3%), and PJF (12.0%) groups.
  • No significant differences in discharge alignment or pre- to post-operative changes were found between groups.
  • Decision tree analysis identified upper instrumented vertebra (UIV) and ΔPJA as key predictors. Patients with a lower thoracic UIV and ΔPJA < 4.3° had a low risk of PJK/PJF.
  • The highest risk group had a lower thoracic UIV, ΔPJA ≥4.3°, and a discharge PJA > 15.5°, with 57.1% developing PJF and 28.6% PJK.

Conclusions:

  • Standing pre-discharge radiographs, particularly PJA and ΔPJA, can predict the risk of junctional complications after spinal fusion.
  • A specific combination of factors—lower thoracic UIV, ΔPJA ≥4.3°, and discharge PJA > 15.5°—identifies a high-risk group for PJF.