Polymethyl methacrylate augmentation and proximal junctional kyphosis in adult spinal deformity patients

Background: Proximal junctional kyphosis (PJK) is a complication following surgery for adult spinal deformity (ASD) possibly ameliorated by polymethyl methacrylate (PMMA) vertebroplasty of the upper instrumented vertebrae (UIV). This study quantifies PJK following surgical correction bridging the thoracolumbar junction ± PMMA vertebroplasty.

Methods: ASD patients from 2013 to 2020 were retrospectively reviewed and included with immediate postoperative radiographs and at least one follow-up radiograph. PMMA vertebroplasty at the UIV and UIV + 1 was performed at the surgeons' discretion.

Results: Of 102 patients, 56% received PMMA. PMMA patients were older (70 ± 8 vs. 66 ± 10, p = 0.021), more often female (89.3% vs. 68.2%, p = 0.005), and had more osteoporosis (26.8% vs. 9.1%, p = 0.013). 55.4% of PMMA patients developed PJK compared to 38.6% of controls (p = 0.097), and the rate of PJK development was not different between groups in univariate survival models. There was no difference in PJF (p > 0.084). Reoperation rates were 7.1% in PMMA versus 11.4% in controls (p = 0.501). In multivariable models, PJK development was not associated with the use of PMMA vertebroplasty (HR 0.77, 95% CI 0.38-1.60, p = 0.470), either when considered overall in the cohort or specifically in those with poor bone quality. PJK was significantly predicted by poor bone quality irrespective of PMMA use (HR 3.81, p < 0.001).

Conclusions: In thoracolumbar fusions for adult spinal deformity, PMMA vertebroplasty was not associated with reduced PJK development, which was most highly associated with poor bone quality. Preoperative screening and management for osteoporosis is critical in achieving an optimal outcome for these complex operations.

Level of evidence: 4, retrospective non-randomized case review.