Spinal Implant Density and Postoperative Lumbar Lordosis as Predictors for the Development of Proximal Junctional Kyphosis in Adult Spinal Deformity

Jamal McClendon*, Timothy R. Smith, Patrick A. Sugrue, Sara E. Thompson, Brian A. O'Shaughnessy, Tyler R. Koski

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Objective To evaluate spinal implant density and proximal junctional kyphosis (PJK) in adult spinal deformity (ASD). Methods Consecutive patients with ASD receiving ≥5 level fusions were retrospectively analyzed between 2007 and 2010. Inclusion criteria: ASD, elective fusions, minimum 2-year follow-up. Exclusion criteria: age <18 years, neuromuscular or congenital scoliosis, cervical or cervicothoracic fusions, nonelective conditions (infection, tumor, trauma). Instrumented fusions were classified by the Scoliosis Research Society–Schwab ASD classification. Statistical analysis consisted of descriptives (measures of central tendency, dispersion, frequencies), independent Student t tests, χ2, analysis of variance, and logistic regression to determine association of implant density [(number of screws + number of hooks)/surgical levels of fusion] and PJK. Mean and median follow-up was 2.8 and 2.7 years, respectively. Results Eighty-three patients (17 male, 66 female) with a mean age of 59.7 years (standard deviation, 10.3) were analyzed. Mean body mass index (BMI) was 29.5 kg/m2 (range, 18–56 kg/m2) with mean preoperative Oswestry Disability Index of 48.67 (range, 6–86) and mean preoperative sagittal vertical axis of 8.42. The mean levels fused were 9.95 where 54 surgeries had interbody fusion. PJK prevalence was 21.7%, and pseudoarthrosis was 19.3%. Mean postoperative Oswestry Disability Index was 27.4 (range, 0–74). Independent Student t tests showed that PJK was not significant for age, gender, BMI, rod type, mean postoperative sagittal vertical axis, or Scoliosis Research Society–Schwab ASD classification; but iliac fixation approached significance (P = 0.077). Implant density and postoperative lumbar lordosis (LL) were predictors for PJK (P = 0.018 and 0.045, respectively). Controlling for age, BMI, and gender, postoperative LL (not implant density) continued to show significance in multivariate logistic regression model. Conclusions PJK, although influenced by a multitude of factors, may be statistically related to implant density and LL.

Original languageEnglish (US)
Pages (from-to)419-424
Number of pages6
JournalWorld neurosurgery
StatePublished - Nov 1 2016


  • Adult spinal deformity
  • Implant density
  • Lumbar lordosis
  • Proximal junctional kyphosis

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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