Retrospective comparative study. We aimed to examine the difference in clinical outcomes in proximal junctional kyphosis (PJK). To date, PJK has been primarily a radiographical finding. Inferior outcomes associated with PJK have not been reported. We performed an analysis of PJK in adult deformity patients to identify risk factors and to evaluate clinical outcomes. A total of 364 patients at a single institution from 2002 to 2007 with adult scoliosis, with an average 3.5 years' follow-up were analyzed. Inclusion criteria were age more than 18 years and fusion greater than 5 levels from any thoracic upper instrumented vertebrae to any lower instrumented vertebrae. Cobb measurements in the coronal and sagittal plane in addition to measurements of the PJK angle at postoperative time points were performed. Clinical assessment was performed using Scoliosis Research Society (SRS) scores and the Oswestry Disability Index. The prevalence of PJK was 39.5% (144/364). The average age in the non-PJK group (n-PJK) was 48.9 versus 53.3 in the PJK group (PJK), and, specifically, age more than 60 years posed a higher prevalence. The prevalence of osteoporosis was 9.8% versus 20.4% in the n-PJK versus PJK groups, respectively. Sex, body mass index, revision surgery, and smoking status were not different between groups. Pain was prevalent in 0.9% versus 29.4% in n-PJK versus PJK, which resulted in lower composite SRS Pain scores (mean change +1.2 vs. +0.8), despite no differences seen in other SRS domains, total SRS score, or Oswestry Disability Index. On multivariate analysis, the presence of pain of the upper back was highly predictive of PJK (odds ratio, 12.5, 95% confidence interval, 2.5-63.2). Radiographically, no differences were seen between groups. However, increasing distance of the upper instrumented vertebrae to C7 plumb line had a higher prevalence of PJK. Instrumentation type, surgical approach, and crosslink use were not different between groups. PJK results in worse clinical outcomes measured by the SRS Pain subscore. Our regression model suggests that pain in the upper back has a strong predictive value for PJK. 3.

Study Design. Retrospective cross-sectional study Objective. Determine if pre-operative cervical alignment serves as an independent predictor of pre-operative disability as measured by the neck disability index (NDI). Summary of Background Data. There is growing interest in the relationship between cervical sagittal alignment and clinical outcomes. While prior studies have shown that C2-C7 sagittal vertical axis (SVA) correlates with worse NDI scores in post-operative patients, no studies to date have examined the impact of cervical sagittal parameters on pre-operative disability in patients indicated for surgery. Methods. Patients with pre-operative standing cervical radiographs, no prior cervical spine procedures and a pre-operative NDI score were identified. Measurements were made by two observers at two different time points. Parameters measured were: Occiput-C2 angle, C1-C2 angle, C2-C7 angle (CL), T1 slope (TS), TS minus CL (TS-CL), C2-C7 SVA, and C1-C7 SVA. Intra- and inter-observer reliability was calculated. Subgroup analyses of myelopathy vs. radiculopathy and deformity vs. no deformity was performed. A multivariate linear regression was performed. Results. Ninety patients were included. Indications included cervical myelopathy (n = 63), cervical radiculopathy (n = 25), cervical stenosis (n = 9), and others (n = 5). CL averaged −13.7 ± 14.9 degrees. TS averaged 30.7 ± 10.4 degrees and C2-C7 SVA averaged 28.8 ± 13.2 mm. Intra- and inter-observer reliability was good to excellent (ICC > 0.8). Increasing CL (r = 0.277, P = 0.009), increasing TS (r = −0.273, P = 0.011) and increasing TS-CL (r = −0.301, P = 0.005) were correlated with decreasing NDI. CL, TS and TS-CL were also strongly correlated with each other (r > 0.65, P < 0.001 for all bivariate correlations). A multivariate regression adjusting for age and indication showed TS-CL (P = 0.040) and C2-C7 SVA (P = 0.015) were independent predictors of NDI. Conclusion. Increasing CL, increasing TS and increasing TS-CL are correlated with decreasingpre-operative NDI. Low TS-CL and high C2-C7 SVA are independent predictors of high pre-operative NDI. Level of Evidence: 4.

Update: This article was updated on November 12, 2019, because of a previous error. On page 349, in Table VII, the column heads “2 Yr”, “Mean Change from Baseline (SE)”, “Difference in Mean Change (95% CI)”, and “P Value” that had been aligned with the content in the second to fourth columns have now been aligned with the content in the third to fifth columns. An erratum has been published: J Bone Joint Surg Am. 2019 Dec 18;101(24):e138. Background: The effectiveness of operative compared with nonoperative treatment at initial presentation (no prior fusion) for adult lumbar scoliosis has not, to our knowledge, been evaluated in controlled trials. The goals of this study were to evaluate the effects of operative and nonoperative treatment and to assess the benefits of these treatments to help treating physicians determine whether patients are better managed operatively or nonoperatively. Methods: Patients with adult symptomatic lumbar scoliosis (aged 40 to 80 years, with a coronal Cobb angle measurement of ≥30° and an Oswestry Disability Index [ODI] score of ≥20 or Scoliosis Research Society [SRS]-22 score of ≤4.0) from 9 North American centers were enrolled in concurrent randomized or observational cohorts to evaluate operative versus nonoperative treatment. The primary outcomes were differences in the mean change from baseline in the SRS-22 subscore and ODI at 2-year follow-up. For the randomized cohort, the initial sample-size calculation estimated that 41 patients per group (82 total) would provide 80% power with alpha equal to 0.05, anticipating 10% loss to follow-up and 20% nonadherence in the nonoperative arm. However, an interim sample-size calculation estimated that 18 patients per group would be sufficient. Results: Sixty-three patients were enrolled in the randomized cohort: 30 in the operative group and 33 in the nonoperative group. Two hundred and twenty-three patients were enrolled in the observational cohort: 112 in the operative group and 111 in the nonoperative group. The intention-to-treat analysis of the randomized cohort found that, at 2 years of follow-up, outcomes did not differ between the groups. Nonadherence was high in the randomized cohort (64% nonoperative-to-operative crossover). In the as-treated analysis of the randomized cohort, operative treatment was associated with greater improvement at the 2-year follow-up in the SRS-22 subscore (adjusted mean difference, 0.7 [95% confidence interval (CI), 0.5 to 1.0]) and in the ODI (adjusted mean difference, −16 [95% CI, −22 to −10]) (p < 0.001 for both). Surgery was also superior to nonoperative care in the observational cohort at 2 years after treatment on the basis of SRS-22 subscore and ODI outcomes (p < 0.001). In an overall responder analysis, more operative patients achieved improvement meeting or exceeding the minimal clinically important difference (MCID) in the SRS-22 subscore (85.7% versus 38.7%; p < 0.001) and the ODI (77.4% versus 38.3%; p < 0.001). Thirty-four revision surgeries were performed in 24 (14%) of the operative patients. Conclusions: On the basis of as-treated and MCID analyses, if a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. If a patient is not satisfied with current spine health and expects improvement, surgery is preferred. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Edictive model. Methods We retrospectively reviewed the charts of all 249 patients with idiopathic scoliosis who underwent surgery from 1996 to 2008. We compared those who developed PJK to those who did not. We identified risk factors for PJK and performed univariate and multivariate analyses to determine independent risk factors. We then used a Cox proportional-hazards model to evaluate the time to the development of PJK. The minimum followup time was 1.5 years (mean, 4 years; range, 1.5-9 years). Results The incidence of PJK in our series of patients with idiopathic scoliosis was 17%. There was no difference in Scoliosis Research Society-22 scores between patients without and with junctional kyphosis. Independent risk factors included proximal fusion to T1 through T3 and sagittal sacral vertical line, while in the Cox model a combined anterior-posterior approach surgery was the most important risk factor. Conclusions Patients with a T1 through T3 upper instrumented level, combined anterior-posterior surgery, and increased sagittal sacral vertical line difference had a higher likelihood of developing PJK. Of these risk factors, anterior-posterior surgery was the strongest risk factor. Level of Evidence Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence....