Cervical Alignment Changes in Patients Developing Proximal Junctional Kyphosis Following Surgical Correction of Adult Spinal Deformity

Neurosurgery. 2018 Oct 1;83(4):675-682. doi: 10.1093/neuros/nyx479.


Background: Proximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery is a well-documented complication, but associations between radiographic PJK and cervical malalignment onset remain unexplored.

Objective: To study cervical malalignment in ASD surgical patients that develop PJK.

Methods: Retrospective review of prospective multicenter database. Inclusion: primary ASD patients (≥5 levels fused, upper instrumented vertebra [UIV] at T2 or above, and 1-yr minimum follow-up) without baseline cervical deformity (CD), defined as ≥2 of the following criteria: T1 slope minus cervical lordosis < 20°, cervical sagittal vertical axis < 4 cm, C2-C7 cervical lordosis < 10°. PJK presence (<10° change in UIV and UIV + 2 kyphosis) and angle were identified 1 yr postoperative. Propensity score matching between PJK and nonPJK groups controlled for baseline alignment. Preoperative and 1-yr postoperative cervical alignment were compared between PJK and nonPJK patients.

Results: One hundred sixty-three patients without baseline CD (54.9 yr, 83.9% female) were included. PJK developed in 60 (36.8%) patients, with 27 (45%) having UIV above T7. PJK patients had significantly greater baseline T1 slope in unmatched and propensity score matching comparisons (P < .05). At 1 yr postoperative, PJK patients had significantly higher T1 slope (P < .001), C2-T3 Cobb (P = .04), and C2-T3 sagittal vertical axis (P = .02). New-onset CD rate in PJK patients was 15%, and 16.5% in nonPJK patients (P > .05). Increased PJK magnitude was associated with increasing T1 slope and C2-T3 SVA (P < .05).

Conclusion: Patients who develop PJK following surgical correction of ASD have a 15% incidence of development of new-onset CD. Patients developing PJK following surgical correction of ASD tend to have an increased preoperative T1 slope. Increased progression of C2-T3 Cobb angle and C2-T3 SVA are associated with development of PJK following surgical correction of thoracolumbar deformity.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Cervical Vertebrae / pathology*
  • Disease Progression
  • Female
  • Humans
  • Incidence
  • Kyphosis / etiology*
  • Male
  • Postoperative Complications / etiology
  • Postoperative Complications / pathology*
  • Propensity Score
  • Spinal Diseases / surgery*
  • Spinal Fusion / adverse effects*
  • Thoracic Vertebrae / pathology
  • Thoracic Vertebrae / surgery