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State of the art: proximal junctional kyphosis—diagnosis, management and prevention

Spine Deformity volume 9, pages 635–644 (2021)Cite this article

A Letter to the Editor to this article was published on 25 September 2021

Abstract

Proximal junctional kyphosis (PJK) is a common problem that may occur following the surgical treatment of adult patients with spinal deformity. It is defined as the proximal junctional sagittal angle from the UIV and UVI + 2 of at least 10° AND at least 10° greater than the preop measurement. The reported incidence of radiographic PJK in the literature varies between 17 and 46%. A smaller subset of these patients may need revision surgery and are defined as proximal junctional failure (PJF), which can be associated with vertebral fracture, vertebral subluxation, failure of instrumentation, and neurological deficits. Several risk factors for development of PJK have been proposed. However, large-scale prospective studies are needed to better identify strategies to reduce the incidence of PJK.

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References

  1. Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976) 30(14):1643–1649

    Article  Google Scholar 

  2. Kim YJ, Bridwell KH, Lenke LG, Rhim S, Kim YW (2007) Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine (Phila Pa 1976) 32(24):2653–2661

    Article  Google Scholar 

  3. Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G (2008) Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. (Phila Pa 1976) 33(20):2179–2184

    Article  Google Scholar 

  4. Bridwell KH, Lenke LG, Cho SK et al (2013) Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery 72(6):899–906

    PubMed  Article  Google Scholar 

  5. Cho KJ, Suk SI, Park SR, Kim JH, Jung JH (2013) Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 22(2):394–401

    PubMed  Article  Google Scholar 

  6. Yagi M, Akilah KB, Boachie-Adjei O (2011) Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976) 36(1):E60-68

    Article  Google Scholar 

  7. Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC (2012) Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976) 37(22l):S144-164

    Article  Google Scholar 

  8. Lau D, Clark AJ, Scheer JK et al (2014) Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976) 39(25):2093–2102

    Article  Google Scholar 

  9. Kim HJ, Iyer S (2016) Proximal junctional kyphosis. J Am Acad Orthop Surg 24(5):318–326

    PubMed  Article  Google Scholar 

  10. Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Koester L, Hensley M (2010) Proximal junctional vertebral fracture in adults after spinal deformity surgery using pedicle screw constructs: analysis of morphological features. Spine (Phila Pa 1976) 35(2):138–145

    Article  Google Scholar 

  11. Mendoza-Lattes S, Ries Z, Gao Y, Weinstein SL (2011) Proximal junctional kyphosis in adult reconstructive spine surgery results from incomplete restoration of the lumbar lordosis relative to the magnitude of the thoracic kyphosis. Iowa Orthop J 31:199–206

    PubMed  PubMed Central  Google Scholar 

  12. Kim HJ, Yagi M, Nyugen J, Cunningham ME, Boachie-Adjei O (2012) Combined anterior-posterior surgery is the most important risk factor for developing proximal junctional kyphosis in idiopathic scoliosis. Clin Orthop Relat Res 470(6):1633–1639

    PubMed  Article  Google Scholar 

  13. Yagi M, King AB, Boachie-Adjei O (2012) Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976) 37(17):1479–1489

    Article  Google Scholar 

  14. Hart RA, McCarthy I, Ames CP, Shaffrey CI, Hamilton DK, Hostin R (2013) Proximal junctional kyphosis and proximal junctional failure. Neurosurg Clin N Am 24(2):213–218

    PubMed  Article  Google Scholar 

  15. Kim HJ, Bridwell KH, Lenke LG et al (2013) Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976) 38(11):896–901

    Article  Google Scholar 

  16. Lau D, Funao H, Clark AJ et al (2016) The clinical correlation of the Hart-ISSG proximal junctional kyphosis severity scale with health-related quality-of-life outcomes and need for revision surgery. Spine (Phila Pa 1976) 41(3):213–223

    Article  Google Scholar 

  17. Yagi M, Rahm M, Gaines R et al (2014) Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity. Spine (Phila Pa 1976) 39(10):E607-614

    Article  Google Scholar 

  18. Hostin R, McCarthy I, O’Brien M et al (2013) Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 38(12):1008–1015

    Article  Google Scholar 

  19. Hart R, McCarthy I, O’Brien M et al (2013) Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity. Spine (Phila Pa 1976) 38(19):E1223-1227

    Article  Google Scholar 

  20. Liu FY, Wang T, Yang SD, Wang H, Yang DL, Ding WY (2016) Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J 25(8):2376–2383

    PubMed  Article  Google Scholar 

  21. Park SJ, Lee CS, Chung SS, Lee JY, Kang SS, Park SH (2017) Different risk factors of proximal junctional kyphosis and proximal junctional failure following long instrumented fusion to the sacrum for adult spinal deformity: survivorship analysis of 160 patients. Neurosurgery 80(2):279–286

    PubMed  Article  Google Scholar 

  22. Maruo K, Ha Y, Inoue S et al (2013) Predictive factors for proximal junctional kyphosis in long fusions to the sacrum in adult spinal deformity. Spine (Phila Pa 1976) 38(23):E1469-1476

    Article  Google Scholar 

  23. Hyun SJ, Kim YJ, Rhim SC (2016) Patients with proximal junctional kyphosis after stopping at thoracolumbar junction have lower muscularity, fatty degeneration at the thoracolumbar area. Spine J 16(9):1095–1101

    PubMed  Article  Google Scholar 

  24. Smith MW, Annis P, Lawrence BD, Daubs MD, Brodke DS (2013) Early proximal junctional failure in patients with preoperative sagittal imbalance. Evid Based Spine Care J 4(2):163–164

    PubMed  PubMed Central  Article  Google Scholar 

  25. Smith MW, Annis P, Lawrence BD, Daubs MD, Brodke DS (2015) Acute proximal junctional failure in patients with preoperative sagittal imbalance. Spine J 15(10):2142–2148

    PubMed  Article  Google Scholar 

  26. Hassanzadeh H, Gupta S, Jain A, El Dafrawy MH, Skolasky RL, Kebaish KM (2013) Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform 1(4):299–305

    PubMed  Article  Google Scholar 

  27. Cahill PJ, Wang W, Asghar J et al (2012) The use of a transition rod may prevent proximal junctional kyphosis in the thoracic spine after scoliosis surgery: a finite element analysis. Spine (Phila Pa 1976) 37(12):E687-695

    Article  Google Scholar 

  28. Cammarata M, Aubin CE, Wang X, Mac-Thiong JM (2014) Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976) 39(8):E500-507

    Article  Google Scholar 

  29. Han S, Hyun SJ, Kim KJ, Jahng TA, Lee S, Rhim SC (2017) Rod stiffness as a risk factor of proximal junctional kyphosis after adult spinal deformity surgery: comparative study between cobalt chrome multiple-rod constructs and titanium alloy two-rod constructs. Spine J 17(7):962–968

    PubMed  Article  Google Scholar 

  30. Buell TJ, Bess S, Xu M et al (2019) Optimal tether configurations and preload tensioning to prevent proximal junctional kyphosis: a finite element analysis. J Neurosurg Spine 1:1–11

    Google Scholar 

  31. Bess S, Harris JE, Turner AW et al (2017) The effect of posterior polyester tethers on the biomechanics of proximal junctional kyphosis: a finite element analysis. J Neurosurg Spine 26(1):125–133

    PubMed  Article  Google Scholar 

  32. Buell TJ, Chen CJ, Quinn JC et al (2019) Alignment risk factors for proximal junctional kyphosis and the effect of lower thoracic junctional tethers for adult spinal deformity. World Neurosurg 121:e96–e103

    PubMed  Article  Google Scholar 

  33. Buell TJ, Buchholz AL, Quinn JC et al (2019) A pilot study on posterior polyethylene tethers to prevent proximal junctional kyphosis after multilevel spinal instrumentation for adult spinal deformity. Oper Neurosurg (Hagerstown) 16(2):256–266

    Article  Google Scholar 

  34. Mummaneni PV, Park P, Fu KM et al (2016) Does minimally invasive percutaneous posterior instrumentation reduce risk of proximal junctional kyphosis in adult spinal deformity surgery? A propensity-matched cohort analysis. Neurosurgery 78(1):101–108

    PubMed  Article  Google Scholar 

  35. Kebaish KM, Martin CT, O’Brien JR, LaMotta IE, Voros GD, Belkoff SM (2013) Use of vertebroplasty to prevent proximal junctional fractures in adult deformity surgery: a biomechanical cadaveric study. Spine J 13(12):1897–1903

    PubMed  Article  Google Scholar 

  36. Martin CT, Skolasky RL, Mohamed AS, Kebaish KM (2013) Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine. Spine Deform 1(2):132–138

    PubMed  Article  Google Scholar 

  37. Theologis AA (2015) Burch S (2015) Prevention of acute proximal junctional fractures after long thoracolumbar posterior fusions for adult spinal deformity using 2-level cement augmentation at the upper instrumented vertebra and the vertebra 1 level proximal to the upper instrumented vertebra. Spine (Phila Pa 1976) 40(19):1516–1526

    Article  Google Scholar 

  38. Raman T, Miller E, Martin CT, Kebaish KM (2017) The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study. Spine J 17(10):1489–1498

    PubMed  Article  Google Scholar 

  39. Reames DL, Kasliwal MK, Smith JS, Hamilton DK, Arlet V, Shaffrey CI (2015) Time to development, clinical and radiographic characteristics, and management of proximal junctional kyphosis following adult thoracolumbar instrumented fusion for spinal deformity. J Spinal Disord Tech 28(2):E106-114

    PubMed  Article  Google Scholar 

  40. Kim HJ, Bridwell KH, Lenke LG et al (2014) Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine (Phila Pa 1976) 39(9):E576-580

    Article  Google Scholar 

  41. Yilgor C, Sogunmez N, Boissiere L et al (2017) Global Alignment and Proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 99(19):1661–1672

    PubMed  Article  Google Scholar 

  42. Noh SH, Ha Y, Obeid I, et al (2019) Modified global alignment and proportion scoring with body mass index and bone mineral density (GAPB) for improving predictions of mechanical complications after adult spinal deformity surgery. Spine J

  43. Ohba T, Ebata S, Oba H, Koyama K, Yokomichi H, Haro H (2019) Predictors of poor global alignment and proportion score after surgery for adult spinal deformity. Spine (Phila Pa 1976) 44(19):E1136–E1143

    Article  Google Scholar 

  44. Bari TJ, Ohrt-Nissen S, Hansen LV, Dahl B, Gehrchen M (2019) Ability of the global alignment and proportion score to predict mechanical failure following adult spinal deformity surgery-validation in 149 patients with two-year follow-up. Spine Deform 7(2):331–337

    PubMed  Article  Google Scholar 

  45. Zhao J, Yang M, Yang Y et al (2018) Proximal junctional kyphosis in adult spinal deformity: a novel predictive index. Eur Spine J 27(9):2303–2311

    PubMed  Article  Google Scholar 

  46. Lafage R, Schwab F, Glassman S et al (2017) Age-Adjusted Alignment Goals Have the Potential to Reduce PJK. Spine (Phila Pa 1976) 42(17):1275–1282

    Article  Google Scholar 

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Funding

This study was not funded by a grant.

Author information

Affiliations

  1. Spine and Scoliosis Surgery, College of Physicians and Surgeons, NewYork-Presbyterian, The Allen Hospital, Columbia University, 5141 Broadway, New York, NY, 3FW, USA

    Zeeshan M. Sardar, Yongjung Kim & Lawrence Lenke

  2. Hospital for Special Surgery, New York, NY, USA

    Virginie Lafage

  3. New England Baptist Hospital, Boston, MA, USA

    Frank Rand

  4. University of California - Davis, Sacramento, CA, USA

    Eric Klineberg

Authors
  1. Zeeshan M. Sardar
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  2. Yongjung Kim
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  3. Virginie Lafage
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  4. Frank Rand
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  5. Lawrence Lenke
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  6. Eric Klineberg
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Consortia

SRS Adult Spinal Deformity Committee

Contributions

ZMS, YK, VL, FR, LL, EK: Contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, Drafting the work or revising it critically for important intellectual content, Final approval of the version to be published and Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Zeeshan M. Sardar.

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Conflict of interest

Dr. Sardar reports personal fees from Medtronic Inc, personal fees from Stryker Spine, outside the submitted work. Dr. Kim has nothing to disclose. Dr. Lenke reports personal fees from Medtronic, grants and personal fees from DePuy-Synthes Spine, personal fees from K2M, non-financial support from Broadwater, non-financial support from Seattle Science Foundation, grants and non-financial support from Scoliosis Research Society, non-financial support from Stryker Spine, non-financial support from The Spinal Research Foundation, grants from EOS, grants from Setting Scoliosis Straight Foundation, personal fees from Fox Rothschild, LLC, personal fees from Quality Medical Publishing, other from Evans Family Donation, other from Fox Family Foundation, grants and non-financial support from AOSpine, outside the submitted work. Dr. Lenke reports personal fees from Medtronic, grants and personal fees from DePuy-Synthes Spine, personal fees from K2M, non-financial support from Broadwater, non-financial support from Seattle Science Foundation, grants and non-financial support from Scoliosis Research Society, non-financial support from Stryker Spine, non-financial support from The Spinal Research Foundation, grants from EOS, grants from Setting Scoliosis Straight Foundation, personal fees from Fox Rothschild, LLC, personal fees from Quality Medical Publishing, other from Evans Family Donation, other from Fox Family Foundation, grants and non-financial support from AOSpine, outside the submitted work. Dr. Lafage reports personal fees from Globus Medical, personal fees from Nuvasive, personal fees from Depuy Synthes Spine, personal fees from The Permanente Medical Group, personal fees from Implanet, outside the submitted work Dr. Rand has nothing to disclose. Dr. Klineberg reports personal fees from Depuy Synthes, personal fees from Stryker, personal fees from Medicrea, grants and personal fees from AOSpine, outside the submitted work.

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Sardar, Z.M., Kim, Y., Lafage, V. et al. State of the art: proximal junctional kyphosis—diagnosis, management and prevention. Spine Deform 9, 635–644 (2021). https://doi.org/10.1007/s43390-020-00278-z

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  • DOI: https://doi.org/10.1007/s43390-020-00278-z

Keywords

  • PJK
  • Junctional kyphosis
  • Junctional failure