Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection

Spine (Phila Pa 1976). 2020 Feb 15;45(4):258-267. doi: 10.1097/BRS.0000000000003249.


Study design: Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database.

Objective: Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone.

Summary of background data: PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF.

Methods: Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) versus within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop.

Results: Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05).

Conclusion: Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.

Level of evidence: 3.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Bone Cements
  • Combined Modality Therapy / methods
  • Databases, Factual
  • Female
  • Follow-Up Studies
  • Humans
  • Kyphosis / diagnostic imaging*
  • Kyphosis / epidemiology
  • Kyphosis / surgery*
  • Male
  • Middle Aged
  • Neurosurgical Procedures / adverse effects
  • Neurosurgical Procedures / methods
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Propensity Score*
  • Prospective Studies
  • Prostheses and Implants*
  • Reoperation / adverse effects
  • Reoperation / methods
  • Retrospective Studies
  • Risk Factors
  • Spinal Fusion / adverse effects
  • Spinal Fusion / methods
  • Treatment Outcome
  • Young Adult


  • Bone Cements