Article


The juxtaposition of these factors, partial vertebral cement filling, a positive sagit- tal balance and structurally-weakened pedicles may set the scene for a very early posterior element distraction failure com- bined with a compression fracture in the uncemented area. Ending the construct too low, just below the apex of the kyphosis, can predispose to junctional kyphosis and compression frac- ture at the cranial level. According to the preoperative radiographs, the upper instru- mented vertebra (T10) was located several levels below the apex (T8). In an attempt to improve the preoperative sagittal imbal- ance we surgically increased the lumbar lordosis (from 45ª preoperatively to 62ª in the postoperative x-ray), this may have led to a new sagittal profile and a greater kyphosis, moving the level of the apex. Attention should be paid to this point, be- cause excessive bending of the rod in the lumbar spine can facilitate the migration of the thoracic kyphosis apex.


, does not solve the problem and may lead to further and more severe fractures, like the one described in this paper, al- though this opinion requires biomechani- cal and/or clinical investigation for confir- mation.


We think that the augmentation of the upper instrumented vertebra and the supra- adjacent level, in an attempt to avoid the complications described by Watanabe et al.6


We would advise that any patient with


a long thoracolumbar fusion with cranial level augmentation be closely monitored.


Consent Written informed consent was obtained from the patient for publication of this Case Re- port and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Our service has used this technique suc- cessfully in more than 15 patients in the last two years. To date, this is the only occurrence of this complication. When successful, vertebral augmentation of the cranial level in a long thoracolumbar fu- sion solves the topping off syndrome and avoids major disabilities.


This is a single case report and does not completely explain high incidence of com- plications in the junctional level after sur- gery for adult spinal deformity. Our pur- pose is to alert the orthopedic community to this phenomenon.


References 1


Hart RA, Prendergast MA, Roberts WG, et al.: Proximal junctional acute collapse cranial to multi-level lumbar fusion: a cost analysis of prophylactic vertebral augmentation. Spine J 2008, 8:875-881.


2


Cahill DW, Etebar S: Risk factors for adjacent segment failure fol- lowing lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg 1999, 90:163-9.


3


Maid ME, Farley S, Holt RT: Preliminary outcomes and efficacy of the first 360 consecutive kyphoplasties for the treatment of painful osteoporotic vertebral compression fractures. Spine J 2005, 5:244-55.


4


Lee MJ, Dumonski M, Cahill P, et al.: Percutaneous treatment of ver- tebral compression fractures: a meta-analysis of complications. Spine 2009, 34:1228-32.


5


Lattig F: Bone cement augmentation in the prevention of adjacent segment failure after multilevel adult deformity fusion. J Spinal Disord Tech 2009, 22:439-443.


6


Watanabe K, Lenke LG, Bridwell KH, et al.: Proximal junctional ver- tebral fracture in adults after spinal deformity surgery using pedicular


screw constructs. Spine 2010, 35:138-145. 7


Bradford DS, Tay BK, Hu SS: Adult scoliosis: surgical indications, operative management, complications and outcomes. Spine 1999, 24:2617-2639.


8


DeWald CJ, Stanley T: Instrumentation-related complications of mul- tilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone qual- ity. Spine 2006, 31(19 suppl):144-151.


9


Kim YJ, Bridwell KH, Lenke LG, et al.: Sagittal thoracic decompen- sation (SThD) following adult lumbar spinal instrumentation and fu- sion to L5 or S1: causes, incidence, and risk factor analysis. Spine 2006, 31:2359-66.


10


Swank ML: Adjacent segment failure above lumbosacral fusions instrumented to L1 or L2. Podium presentation at the Scoliosis Re- search Society 37th annual meeting. September 18-21; Seattle, WA. USA; 2002.


11


Suk SI, Kim JH, Lee SM, et al.: Incidence of proximal adjacent fail- ure in adult lumbar deformity correction. Podium presentation at the Scoliosis Research Society 38th annual meeting. September 10-13; Quebec City, Canada; 2003.


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34 | SpinalSurgeryNews | Autumn 2012 Competing interests


The authors of this paper do not have any conflict of interest, financial or non-finan- cial, related with the study.


Authors’ contribution


NFB and FJSPG performed the first sur- gery. NFB, AGF and JMSM performed the second surgery. All authors participated in the design and redaction of the text and conclusions, and posterior corrections. All authors read and approved the final manu- script.


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