Objective Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common complications following long-segment spinal fusion, particularly in adult spinal deformity (ASD) correction surgery. Various surgical techniques have been proposed to prevent these complications, but high-quality evidence remains limited. This study aimed to evaluate the effectiveness of surgical strategies for preventing PJK and PJF after ASD correction or long-segment spinal fusion in adults.
Methods A systematic search was conducted in PubMed, Embase, and the Cochrane Library through March 2025. Eligible studies included adults who underwent ASD surgery or long-segment (≥4 levels) posterior spinal fusion, comparing PJK or PJF incidence across surgical techniques such as tethering, hook fixation, prophylactic vertebral augmentation, rod characteristics, and upper instrumented vertebra (UIV) level. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model.
Results Thirty-eight retrospective studies were included in the systematic review and 33 in the meta-analysis. Spinous process tethering reduced PJK incidence (OR, 0.35; 95% CI, 0.22–0.56). Hook fixation (OR, 0.34; 95% CI, 0.21–0.55) and prophylactic vertebral augmentation (OR, 0.58; 95% CI, 0.35–0.95) reduced PJF incidence. Lower PJK rates were observed with UIV at T10 or above (OR, 0.15; 95% CI, 0.03–0.64) and lower PJF rates with UIV at L1 or above (OR, 0.29; 95% CI, 0.14–0.61).
Conclusion Surgical strategies such as tethering, hook fixation, and prophylactic vertebral augmentation may reduce the risk of PJK/PJF. Additionally, placing the UIV at or slightly above T10 may enhance junctional stability. Further prospective studies are needed to validate these findings and guide preventive strategies.
Objective Spinal fusion surgery is effective for treating various adult spinal deformities. However, spinal fusion surgery is associated with the risk of adjacent segment disease (ASD; 5%–30%), particularly proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). Proximal junctional tethering (PJT) has become a popular technique owing to increasing evidence that it can decrease the rate of PJK or PJF.
Methods A literature search was conducted using PubMed, Embase, and Cochrane Library. Twelve eligible studies were identified. These studies were predominantly retrospective in nature and compared the incidence of PJK or PJF in adults undergoing spinal fusion surgery with or without PJT. Risk of bias was assessed using the Newcastle-Ottawa scale. All outcomes were analyzed using R software (ver. 4.4.1).
Results We included 8 retrospective cohort studies and 3 propensity-score-matched analyses; these studies comprised 1,424 patients. PJT was associated with a significant decrease in the odds of development of PJK (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.27–0.71) and PJF (OR, 0.36; 95% CI, 0.19–0.69) compared with control. Subgroup analysis results revealed no significant difference in ASD rates between geographical locations, between tethering with and without crosslinks, and between specific tethering techniques.
Conclusion PJT significantly reduces the odds of both PJK and PJF in adults undergoing spinal fusion surgery.
Objective To assess the effectiveness of vertebral cement augmentation (VCA) at upper instrumented vertebra (UIV) and UIV+1 in preventing proximal junction complications in correction surgery for adult spinal deformity patients.
Methods A literature search was conducted on Web of Science, PubMed, and Cochrane Library databases for comparative studies published before December 30th, 2024. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed study quality with Newcastle-Ottawa scale, and extracted data like study characteristics, surgical details, primary and secondary outcomes. Data analysis was performed using Review Manager 5.4 and Stata software.
Results Of all 513 papers screened, a meta-analysis was conducted on 7 articles, which included 333 cases in the VCA group and 827 cases in the control group. Patients in the VCA group had significantly older age and lower T score than patients in the control group. Although there was no statistically significant difference in the incidence of proximal junctional failure between the 2 groups, the results of the meta-analysis showed that the incidence of proximal junctional failure and the need for revision surgery were reduced by 36% and 71%, respectively, in the VCA group. One study reported 2 clinically silent pulmonary cement embolism and 1 patient requiring surgical decompression for cement leak into the spinal canal.
Conclusion This meta-analysis supported the use of VCA in corrective surgery for spinal deformities patients, especially in patients with advanced age and osteoporosis.
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Objective To identify the risk factors for proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery despite ideal sagittal correction according to age-adjusted alignment target.
Methods The study included patients who underwent low thoracic to pelvic fusion for ASD and obtained ideal correction according to age-adjusted pelvic incidence minus lumbar lordosis. PJF was defined either radiographically as a proximal junctional angle (PJA) of >28° plus a difference in PJA of >22° or clinically as revision surgery for proximal junctional complications. Clinical and radiographic variables were assessed to identify the risk factors for PJF.
Results The final study cohort consisted of 196 patients, of whom 170 were women (86.7%), with an average age of 68.3 years. During mean follow-up duration of 45.9 months, PJF occurred in 43 patients (21.9%). Multivariate logistic regression analysis revealed that old age (odds ratio [OR], 1.063; 95% confidence interval [CI], 1.001–1.129; p=0.046), large preoperative sagittal vertical axis (OR, 1.007; 95% CI, 1.001–1.013; p=0.024), nonuse of a transverse process (TP) hook (OR, 5.556; 95% CI, 1.205–19.621; p=0.028), and high lumbar distribution index (LDI) (OR, 1.136; 95% CI, 1.109–1.164; p<0.001) were significant risk factors for PJF development.
Conclusion A sizeable proportion of patients (21.9%) developed PJF despite achieving ideal sagittal correction. Using TP hooks with avoiding excessive LDI can be helpful to further mitigate the risk of PJF development in this patient group.
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Adult spinal deformity (ASD) surgery aims to correct abnormal spinal curvature in adults, leading to improved functionality and reduced pain. However, this surgery is associated with various complications, one of which is proximal junctional failure (PJF). PJF can have a significant impact on a patient’s quality of life, necessitating a comprehensive understanding of its causes and the development of effective management strategies. This review aims to provide an in-depth understanding of PJF in ASD surgery. PJF is a complex complication resulting from a multitude of factors including patient characteristics, surgical techniques, and postoperative management. Age, osteoporosis, overcorrection of sagittal alignment, and poor bone quality are identified as significant risk factors. The clinical implications of PJF are substantial, often requiring revision surgery and causing a considerable decrease in patients’ quality of life. Prevention strategies include careful preoperative planning, appropriate patient selection, and optimization of surgical techniques. Treatment often necessitates a multifaceted approach, including surgical intervention and the management of underlying risk factors. Predictive modeling is an emerging field that may offer a promising avenue for the risk stratification of patients and individualized preventive strategies. A thorough understanding of PJF’s pathogenesis, risk factors, and clinical implications is essential for surgeons involved in ASD surgery. Current preventive measures and treatment strategies aim to mitigate the risk and manage the complications of PJF, but the complication cannot be entirely prevented. Future research should focus on the development of more effective preventive and treatment strategies, and predictive models could be valuable in this pursuit.
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Proximal junction kyphosis (PJK) is a common imaging finding after long-level fusion, and proximal junctional failure (PJF) is an aggravated form of the progressive disease spectrum of PJK. This includes vertebral fracture of upper instrumented vertebra (UIV) or UIV+1, instability between UIV and UIV+1, neurological deterioration requiring surgery. Many studies have reported on PJK and PJF after long segment instrumentation for adult spinal deformity (ASD). In particular, for spine deformity surgeons, risk factors and prevention strategies of PJK and PJF are very important to minimize reoperation. Therefore, this review aims to help reduce the occurrence of PJK and PJF by updating the latest contents of PJK and PJF by 2023, focusing on the risk factors and prevention strategies of PJK and PJF. We conducted a search on multiple database for articles published until February 2023 using the search keywords “proximal junctional kyphosis,” “proximal junctional failure,” “proximal junctional disease,” and “adult spinal deformity.” Finally, 103 papers were included in this study. Numerous factors have been suggested as potential risks for the development of PJK and PJF, including a high body mass index, inadequate postoperative sagittal balance and overcorrection, advanced age, pelvic instrumentation, and osteoporosis. Recently, with the increasing elderly population, sarcopenia has been emphasized. The quality and quantity of muscle in the surgical site have been suggested as new risk factor. Therefore, spine surgeon should understand the pathophysiology of PJK and PJF, as well as individual risk factors, in order to develop appropriate prevention strategies for each patient.
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Objective To investigate prevention of proximal junctional kyphosis (PJK) and failure (PJF) following adult spinal deformity (ASD) surgery utilizing a novel technique of posterior ligament augmentation with polyester fiber tether.
Methods This study evaluated ASD adult patients who underwent posterior decompression and instrumented fusion from the thoracolumbar junction (T9–L1) to the pelvis from 2011–2017. Basic demographic data were obtained. Radiographic outcomes included proximal junctional angle (PJA), sagittal vertical axis, PJK, and PJF. The study population was divided into patients who had ASD surgery with and without ligamentous augmentation.
Results A total of 43 subjects were evaluated, including 20 without and 23 with ligamentous augmentation. PJA increased over time for both groups. PJA was smaller for the augmented group, and rate of increase in PJA was slower in the augmented group (p < 0.0001). The rate of PJK was significantly higher in the nonaugmented group (p = 0.01). PJF was significantly less common in the augmented group (p = 0.003). Time to revision surgery was lower in the nonaugmented group (p = 0.003).
Conclusion Our novel ligament augmentation technique utilizing polyethylene tape is an effective technique to slow progression of the PJA and lower the risk for proximal junctional disease in ASD surgery.
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The purpose of this review is the current understanding of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery. We carried out a systematic search of PubMed for literatures published up to September 2017 with “proximal junctional kyphosis,” “proximal junctional failure,” and “adult spinal deformity” as search terms. A total of 98 literatures were searched. The 37 articles were included in this review. PJK is multifactorial in origin and likely results from variable risk factors. PJF is a progressive form of the PJK spectrum including bony fracture, subluxation between UIV and UIV+1, failure of fixation, neurological deficit, which may require revision surgery for proximal extension of fusion. Soft tissue protections, adequate selection of the UIV, prophylactic rib fixation, hybrid instrumentation such as hooks, vertebral cement augmentation at UIV and UIV+1, adequate selection material of rods and age-appropriate spinopelvic alignment goals are strategies to minimize PJK and PJF. The ability to perform aggressive global realignment of spinal deformities has also led to the discovery of new complications such as the PJK and PJF. Continuous research on PJK and PJF should be proceeded in order to comprehend the pathophysiology of these complications.
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