Objective We aimed to investigate the incidence of delayed-onset neurological deficits (DONDs), DOND-related reoperation rates following adult spinal deformity (ASD) surgery, and efficacy of transverse process hooks (TPHs) at the uppermost instrumented vertebra (UIV) compared to pedicle screws (PSs).
Methods We included 90 consecutive patients who underwent instrumented fusion from the sacrum to the distal thoracic spine for ASD, with a minimum follow-up of 24 months. Clinical and radiological outcomes were compared between 33 patients in the TPH group and 57 patients in the PS group, using the Scoliosis Research Society-22 Outcomes questionnaire (SRS-22), Medical Outcomes Study Questionnaire Short-Form 36 (SF-36), and various spinal sagittal parameters.
Results While absent in the TPH group, myelopathy occurred in 15.8% of the PS group, wherein 15 patients underwent reoperation. The change in the proximal junctional angle, from the pre- to postoperative assessment, was lower in the TPH group than in the PS group (0.2 vs. 6.6, p=0.002). Postoperative facet degeneration in the PS group progressed more significantly than in the TPH group (0.5 vs. 0.1, p=0.002). Surgical outcomes were comparable for both groups, except for the back visual analogue scale (3.5 vs. 4.1, p=0.010) and SRS-22 domains, including pain and satisfaction (3.3 vs. 2.9, p=0.033; 3.7 vs. 3.3, p=0.041). No intergroup difference was observed in SF-36.
Conclusion Using TPHs at the UIV level can prevent DOND, and thereby prevent postoperative myelopathy that necessitates reoperation; thus, TPHs is preferable over PSs in ASD surgery.
Citations
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Clinical and radiological outcomes of transverse process hooks versus pedicle screws at the upper instrumented vertebra in adult spinal deformity patients undergoing three-column osteotomy: A retrospective comparative study Mohsen Rostami, Sadegh Bagherzadeh, Navid Moghadam, Faramarz Roohollahi, Cesar Carballo Cuello, Jay Kumar, Mark Greenberg, Puya Alikhani Clinical Neurology and Neurosurgery.2026; 261: 109263. CrossRef
Comparison of Hook Fixation and Vertebroplasty for Prevention of Proximal Junctional Failure: A Retrospective Cohort Study Sung Tan Cho, Jae Hwan Cho, Dong-Ho Lee, Chang Ju Hwang, Sehan Park, Jin Hwan Kim, Wongthawat Liawrungrueang Global Spine Journal.2026;[Epub] CrossRef
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Objective Few studies have reported radiographic and clinical outcomes of transverse process hook (TPH) placement at the proximal thoracic upper instrumented vertebra (UIV) in adult spinal deformity (ASD) surgery. This study aims to investigate radiographic and clinical outcomes of TPH placement at the UIV for ASD surgery.
Methods This is a retrospective cohort of 56 patients with ASD (age, 59 ± 13 years; followup, 44 ± 19 months) from Johns Hopkins Hospital, who underwent long posterior spinal fusion to the proximal thoracic spine (T2–5). Visual analogue scale (VAS) for back pain, Oswestry Disability Index (ODI), 36-item Short Form health survey scores, thoracic kyphosis (TK), lumbar lordosis, sacral slope, pelvic tilt, pelvic incidence, proximal junctional kyphosis (PJK) angle, PJK incidence, pattern of PJK, grades of TPH dislodgement, revision surgery, and factors associated with high-grade TPH dislodgement were analyzed.
Results VAS for back pain and ODI values improved significantly from preoperatively to final follow-up. Mean change in PJK angle was 12° (range, 0.5°–43°). Twenty patients (36%) developed PJK, of whom 13 had compression fractures at 1 vertebra distal to the UIV (UIV–1). Final TPH position was stable in 42 patients (75%). In most patients (86%), TPH dislodgement did not progress after 6-month postoperative follow-up. Three patients (5.3%) underwent revision surgery to extend the fusion because of symptomatic PJK. Unstable TPH position was associated only with revision surgery and TK.
Conclusion TPH placement at the proximal thoracic UIV for long fusion showed favorable clinical and radiographic outcomes in terms of the incidence of PJK and mean PJK angle at mean 44-month follow-up. TPHs placed in the proximal thoracic UIV were in stable position in 75% of patients. Compression fracture at UIV–1 was the most common pattern of PJK. PJK angle progression was greater in revision cases and in patients with greater preoperative thoracic kyphosis.
Citations
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Effects of paraspinal muscle atrophy and fatty degeneration on segmental kyphosis after conservative treatment of osteoporotic vertebral compression fracture (OVCF) in postmenopausal women Inwook Seo, Minjoon Cho, Taehoon Kang, Sungtaek Chung, Jae Hyup Lee European Spine Journal.2026; 35(5): 2622. CrossRef
Clinical and radiological outcomes of transverse process hooks versus pedicle screws at the upper instrumented vertebra in adult spinal deformity patients undergoing three-column osteotomy: A retrospective comparative study Mohsen Rostami, Sadegh Bagherzadeh, Navid Moghadam, Faramarz Roohollahi, Cesar Carballo Cuello, Jay Kumar, Mark Greenberg, Puya Alikhani Clinical Neurology and Neurosurgery.2026; 261: 109263. CrossRef
Proximal Junctional Kyphosis Prevention in Adult Spinal Deformity Surgery: A Technical Review of Tethering and Adjunctive Strategies Paritash Tahmasebpour, Pawel P. Jankowski, Jason Liang, Joshua Lin, Kyriakos D. Chatzis, Peter S. Tretiakov, Spencer Matthews, Louis Boissiere, John F. Burke, Christopher I. Shaffrey, Aaron Hockley, Peter Passias Operative Neurosurgery.2026;[Epub] CrossRef
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