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Purpose <p>VPAs quantify the spatial relationship of each vertebra to the pelvis and are independent of patient positioning, making them a valuable tool for preoperative planning and intraoperative assessment of sagittal alignment. Given the biomechanical relevance of vertebral pelvic angles (VPAs), their role in predicting proximal junctional kyphosis (PJK) warrants further investigation. We hypothesized that malalignment of VPAs is associated with an increased risk of developing PJK following long-segment fusion for adult spinal deformity (ASD).</p> Methods <p>ASD patients ≥ 18&#xa0;years undergoing ≥ 5-level posterior spinal instrumentation and fusion (PSIF) to the pelvis from 2015 to 2022 were included. VPAs (C2PA, T1PA, T4PA, T10PA, L1PA) were measured on standardized radiographs preoperatively and immediately postoperatively. PJK was defined radiographically by two criteria: (1) a postoperative proximal junctional sagittal Cobb angle ≥ 10°, and (2) an increase of ≥ 10° compared to the preoperative angle between the UIV and UIV + 2. Associations between VPA changes, published alignment thresholds (L1PA = PI × 0.5 − 19° ± 2°; T4–L1PA mismatch = − 3° to + 1°), and PJK were assessed using ROC analysis and logistic regression.</p> Results <p>A total of 266 patients (mean age: 57.5 ± 12.5&#xa0;years; 74.8% female; mean follow-up: 24.6 ± 13.7&#xa0;months) were included. Forty-five patients (16.9%) developed PJK, of which 37.8% were symptomatic. VPAs correlated most strongly with pelvic tilt (r up to 0.766). In the overall cohort, mean postoperative VPA values and changes were not significantly different between PJK and no-PJK groups. However, in a subgroup with UIV ≥ T5 (n = 174), patients with PJK demonstrated greater corrections in C2PA (14.3° vs. 8.0°, p &lt; 0.001), T1PA (14.6° vs. 9.0°, p = 0.005), T4PA (12.9° vs. 8.3°, p = 0.016), T10PA (10.1° vs. 6.2°, p = 0.004), and L1PA (8.3° vs. 5.4°, p = 0.006). ROC demonstrated C2PA change held the highest predictive value for PJK (AUC = 0.64), followed by L1PA change (AUC = 0.62). Adherence to the published L1PA threshold and optimizing T4-L1PA mismatch to near neutral was protective against PJK in this cohort.</p> Conclusion <p>Our results demonstrate that greater magnitude correction of VPAs from baseline, particularly C2PA and L1PA, was associated with an increased risk of PJK in longer constructs with a UIV proximal to T5. Furthermore, this study is consistent with prior work suggesting that L1PA and T4–L1 mismatch may be useful parameters when assessing sagittal alignment in relation to PJK risk.</p>

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Vertebral pelvic angles accurately predict risk of proximal junctional kyphosis following long-segment fusion for adult spinal deformity

  • 期刊论文

  • 发表日期：

    2026年4月25日

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  • Michael W. Fields,
  • Justin K. Scheer,
  • Matthew Weintraub,
  • Juan Baltazar,
  • Fthimnir Hassan,
  • Omar Taha,
  • Anastasia M. Ferraro,
  • Erik Lewerenz,
  • Matthew J. Cooney,
  • Joseph M. Lombardi,
  • Zeeshan M. Sardar,
  • Lawrence G. Lenke,
  • Ronald A. Lehman

摘要

Purpose

VPAs quantify the spatial relationship of each vertebra to the pelvis and are independent of patient positioning, making them a valuable tool for preoperative planning and intraoperative assessment of sagittal alignment. Given the biomechanical relevance of vertebral pelvic angles (VPAs), their role in predicting proximal junctional kyphosis (PJK) warrants further investigation. We hypothesized that malalignment of VPAs is associated with an increased risk of developing PJK following long-segment fusion for adult spinal deformity (ASD).

Methods

ASD patients ≥ 18 years undergoing ≥ 5-level posterior spinal instrumentation and fusion (PSIF) to the pelvis from 2015 to 2022 were included. VPAs (C2PA, T1PA, T4PA, T10PA, L1PA) were measured on standardized radiographs preoperatively and immediately postoperatively. PJK was defined radiographically by two criteria: (1) a postoperative proximal junctional sagittal Cobb angle ≥ 10°, and (2) an increase of ≥ 10° compared to the preoperative angle between the UIV and UIV + 2. Associations between VPA changes, published alignment thresholds (L1PA = PI × 0.5 − 19° ± 2°; T4–L1PA mismatch = − 3° to + 1°), and PJK were assessed using ROC analysis and logistic regression.

Results

A total of 266 patients (mean age: 57.5 ± 12.5 years; 74.8% female; mean follow-up: 24.6 ± 13.7 months) were included. Forty-five patients (16.9%) developed PJK, of which 37.8% were symptomatic. VPAs correlated most strongly with pelvic tilt (r up to 0.766). In the overall cohort, mean postoperative VPA values and changes were not significantly different between PJK and no-PJK groups. However, in a subgroup with UIV ≥ T5 (n = 174), patients with PJK demonstrated greater corrections in C2PA (14.3° vs. 8.0°, p < 0.001), T1PA (14.6° vs. 9.0°, p = 0.005), T4PA (12.9° vs. 8.3°, p = 0.016), T10PA (10.1° vs. 6.2°, p = 0.004), and L1PA (8.3° vs. 5.4°, p = 0.006). ROC demonstrated C2PA change held the highest predictive value for PJK (AUC = 0.64), followed by L1PA change (AUC = 0.62). Adherence to the published L1PA threshold and optimizing T4-L1PA mismatch to near neutral was protective against PJK in this cohort.

Conclusion

Our results demonstrate that greater magnitude correction of VPAs from baseline, particularly C2PA and L1PA, was associated with an increased risk of PJK in longer constructs with a UIV proximal to T5. Furthermore, this study is consistent with prior work suggesting that L1PA and T4–L1 mismatch may be useful parameters when assessing sagittal alignment in relation to PJK risk.